STANDARD 
MEDICAL  PUBLICATIONS 

WM.  T.  COI.LIER. 

43CUV  Bank  Buililin^'. 

Buffalo.  N.  \ 


GLP  I  Z( 


Coluttrfjia  ®mbersittp 

CoUege  of  S^f)psiitiansi  anb  ^uvQtoni 


33r.  Halter  K5.  f  ameg 


Respiratory  Exercises 


TREATMENT  OF  DISEASE. 


XOTAnLV  OF  THE  HEART,   LUNGS,    MiRlOi'S 
AXn  DH.ESTIl'E  SYSTEMS. 


KY 


HARRY    CAxMPBELL,    M.D.,    B.S.,    Loxd. 

Fellow  of  the  Royal  College  of  Physicians.  Londo.n, 

Physician  to  the  Xorth-west  1,o.vdon  Hospit.^l,  a>jd  to  Hospital  fok  diseases 

OF  the  Nervous  System,  Welbeck  Street. 


NEW    YORK : 

WILLIAM    WOOD   AND    COMPANY. 

MDCCCXCIX. 


G 


PREFACE 


By  modifying  the  respiratory  movements  in  certain  ways  we 
can  produce  profound  effects  upon  the  organism.  Not  only 
can  we  regulate  the  absorption  of  oxygen  and  the  elimina- 
tion of  the  respiratory  excreta,  but  we  can  also  influence 
the  circulation  of  blood  and  lymph,  both  generally  and 
locally. 

Now,  it  occurred  to  me  that  some  of  these  effects  might 
be  useful  in  the  treatment  of  disease,  and  after  prolonged 
and  careful  investigation  I  have  come  to  the  conclusion 
that  properly-devised  respiratory  exercises  have  a  great 
therapeutical  value. 

This  mode  of  treatment  being  founded  on  physiological 
principles,  it  has  been  necessary  to  define  those  principles, 
and  this  has  involved  a  somewhat  severely  technical 
exposition.  Those  who  have  not  the  leisure  nor  the 
inclination  to  study  this  portion  of  the  book  may  proceed 
at  once  to  the  more  practical  portion  of  it,  beginning 
at  Chapter  XX. 

The  present  work  is  the  outgrowth  of  a  larger  one  on  the 
mechanical  treatment  of  heart  disease,  a  subject  which  has 


IV  PREFACE 

occupied  my  thoughts  from  the  very  outset  of  my  medical 
career.  It  was  not  until  the  book  was  well  advanced  that  I 
became  aware  that  I  had  been  in  a  measure  forestalled  by 
the  physicians  of  Nauheim.  Their  therapeutical  methods 
were  arrived  at  empirically  ;  mine  by  an  application  of 
physiological  principles.  Each  line  of  investigation  has 
a  value  of  its  own ;  and  just  as  I  have  been  able  to 
supplement  my  methods  by  the  empirical  methods  of 
Nauheim,  so  conversely,  as  I  shall  hope  to  show  in  this 
and  my  larger  work,  the  Nauheim  methods  may  be  ex- 
tended and  corrected  by  applying  the  truths  of  physiology. 

HAERY  CAMPBELL. 


23,  WiMPOLE  Street,  London,  W. 


CONTENTS 


CHAPTER  PAOb 

I.  The    Elasticity    of    the    Lungs  —  Pulmonary 

Suction     ------  1 

MEANS        for        maintaining        PULMONARY 

elasticity  -           -           -           -           -  7 

II.  Intra- Abdominal    Tension — Functions    of    the 

Abdominal  Muscles        -           -           .           -  9 
secondary     effects      of      low     intra- 
abdominal tension           -           -           -  12 

THE   action    of   THE   ABDOMINAL   MUSCLES      -  15 

METHOD     OF     TESTING     THE     TONE      OF      THE  "^ 

ABDOMINAL   MUSCLES                -                 -                 -  16 

III.  The  Elasticity  of  the  Thoracic  Cage    -           -  19 

IV.  The   Factors   determining   the   Mean   Size  of 

THE  Chest             -            -            -            -            -  25 

V.  The  Mobility  of  the  Thoracic  Cage       -           -  32 

means  of  testing  thoracic  mobility        -  35 

VT.  The  Pleur/E  and  their  Functions — The  Move- 
ments OF  the  Lungs       -           -           -           -  37 
the  lower  limits  of  the  pleura             -  38 
the  movements  of  the  lungs  within  the 
chest          -            -            -            -            -  39 

VII,  Inspiratory  and  Expiratory  Force         -           -  43 

the  breath-force  in  disease         -            -  45 

RELATIVE     strength     OF     THE     INSPIRATORY 

AND   EXPIRATORY  MUSCLES                 -                -  46 


VI  CONTENTS 

CHAPTER  PAGE 

VIIT.  The  Eespiratory  Forces  -  -  -  -      48 

IX.  Modes  in  which  the  Thorax  is  Enlarged       -      54 

THE   QUANTITY    OF    AIR   THAT  CAN  BE   EXPIRED 

BY   DIFFERENT   METHODS   OF   BREATHING         -         60 

X.  Breathing  in  Singers       -  -  -  -      64 . 

1.  CLAVICULAR   BREATHING         -  -  -  64 

2.  LOWER   COSTAL   BREATHING  -  -  -  65 

3.  LOWER   COSTO-ABDOMINAL  BREATHING  -  66 

4.  PURE   ABDOMINAL   BREATHING  -  -  67 

5.  ABDOMINO-COSTAL   BREATHING    =         -  -  69 

XL  Vital  Capacity       -  -  -  -  -      75 

THE     practical     VALUE     OF     GAUGING    VITAL 

CAPACITY  :   VALUE   IN   DIAGNOSIS        -  -        77 

THE   QUANTITY    OF   RESIDUAL   AIR  -  -         78 

XII.  Secondary  Effects  of  the  Respiratory  Move- 
ments        -  -  -  -  -  -      79 

XIII.  Influence  of  the  Eespiratory  Movements  on 

THE  Circulation  of  the  Blood  -  -      81 

influence  of  the  respiratory  movements 

on  arterial  and  venous  tension  -      94 

influence  of  the  respiratory  movements 
ON  the  pulse-rate  -  -  -  -      97 

THE  effects  of  THE  RESPIRATORY  MOVE- 
MENTS  ON  THE   CEREBRAL  CIRCULATION         -        98 

XIV.  The  Influence  upon  the  Circulation,  etc.,  of 

Modifications  in  the  Density  of  the  Outer 

Air -    101 

the   effects    of    immersing  the  body   in 

compressed  air       -  -  -  -    102 

the  effects  of  rarefied  air  -  -     102 

the  effects  upon  the  circulation  of 
varying  the  density  of  the  air  in- 
spired and  expired  into,  the  general 
atmospheric     pressure    remaining    the 

SAME  -  -  -  -  -      103 


CONTENTS 


Vll 


CHAPTER  PAOE 

XV.  Influence  of  the  Rkspiratory  Movements  on 

THE  Circulation  of  Lymph    -           -           -  106 
XVI.  Physiological  Modifications  in  the  Respira- 
tory Movements          -            -            -            -  109 
diminution  in  the  frequency  and  depth 

of  the  respiratory  movements  -  110 

increased  frequency  and   depth,  and 

altered  rhythm  from  muscle-exercise  111 
modifications  in  the  respiratory  move- 
ments leading  to  augmented  intra- 

pulmonary  tension      -  -  -  112 

XVII.  Normal   Modifications   of   the   Respiratory 
iMovEMENTS   {continued) :   Talking,   Shouting, 

Singing,  Coughing,  Crying,  Sighing  -  117 

talking      -  -  -  -  -  118 

shouting    -  -  -  -  -  121 

SINGING         -  -  -  -        •        -  122 

laughter   -  -  -  -  -  125 

CRYING  -  -  -  -  -  125 

YAWNING      -  -  -  -  -  127 

XVIII.  Impediments  to  the  Respiratory  Movements  129 

impediments   to   COSTAL   BREATHING             -  129 
IMPEDIMENTS   TO   DIAPHRAGMATIC    BREATH- 
ING             -                -                 -                -                -  135 

XIX.  Hyperoxygenation  of  the  Blood — Dyspn(ea-  140 

hyperoxygenation  of  the  blood  -  140 

dyspnoea     -  -  -  -  -  142 

XX.  On     THE     Various     Kinds     of     Breathing 

Exercises  -  -  -  -  -  145 

preliminary  observations  -  -  145 

preliminary  exercises     -  -  -  148 

active  breathing  exercises       -  -  152 

breathing    exercises    conjoined    with 

active  exercises          -           -           -  155 
passive  respiratory  exercises  -           -  157 
exercises    for    developing   the   abdo- 
minal muscles  -           -          -           -  160 


Vlll  CONTENTS 

CHAPTER  PACE 

XXI.  Respiratory   Exercises   in   Diseases  of   the 

Lungs    ------  166 

as  a  preventative  of  pulmonary  disease  166 
as    a    means    of   treating   pulmonary 

DISEASE     -----  168 

XXII.  Respiratory  Exercises  in  Emphysema  -  174 

TREATMENT   OF   EMPHYSEMA  -  -  181 

XXIII.  Respiratory  Exercises  in  Heart  Disease      -  185 

XXIV.  Respiratory  Exercises  in  the  Treatment  of 

Nervous  Diseases       -  -  -  -  189 

XXV.  Respiratory  Exercises  in  the  Treatment  of 

Digestive  Disorders   -  -  -  -  192 

XXVI.  Respiratory  Exercises  in  Other  Diseases     -  194 

gall-stones  .  -  -  -  194 

obesity      -----  195 

anemia       -  -  -  -  -  195 

epistaxis    -  -  -  -  -  196 

stammering  -  -  -  -  196 

hiccough    -  -  -  -  -  196 

sleeplessness        -  -  -  -  196 

Index        -  -  -  -  -  -  197 


RESPIRATORY    EXERCISES 

IN    THE 

TREATMENT  OF  DISEASE 


CHAPTEK    L 

THE  ELASTICITY  OF  THE  LUNGS— PULMONARY 
SUCTION. 

The  lungs  occupy  that  part  of  the  thorax  not  occupied  by 
the  mecliastina,  but  they  are  not  large  enough  to  fill  this 
space  without  a  considerable  stretching  of  the  elastic  fibres 
■with  which  they  are  richly  furnished,  and  hence  they  are 
ever  tending  to  contract,  this  tendency  increasing  during 
inspiration  and  during  contraction  of  the  bronchial  muscles. 
The  pressure  of  the  atmosphere  within  them,  however, 
counteracts  the  tendency,  and  keeps  them  closely  applied 
to  the  chest-walls,  heart,  aorta,  and  other  contiguous  struc- 
tures. When  the  chest  is  opened  after  death,  and  the 
atmosphere  allowed  to  press  upon  the  outside  of  the 
lungs  as  well  as  from  within,  they  necessarily  undergo 
considerable  contraction.  Hence,  we  must  think  of  these 
organs  as  ever  striving  to  break  away  from  their  surround- 
ings, and  as  thus  exercismg  a  negative  pressure  or  suction 
upon  them.     We  may  speak  of  this  as  pulmoiiarn  siirtioii,^ 

*  Some  authors  write  of  the  lungs  as  exercismg  traction  upon  the 
contiguous  structures ;  but  this  is  not  strictly  accurate,  inasmuch  as 

1 


is  RESPIRATORY    EXERCISES 

and  it  is  owing  to  it  that  the  pressure  in  the  pleurae  and 
pericardium  is  negative.* 

From  the  foregoing  remarks  it  will  be  clear  that  the 
lungs  in  no  sense  suj)port  the  chest-walls,  but,  on  the 
contrary,  tend  to  suck  them  in.  It  is  only  towards  the  end 
of  a  deep  expiration,  or  when  an  expiratory  effort  is  made 
with  closed  glottis,  that  they  exert  anywhere  a  positive 
pressure.  In  the  latter  case  they  may  be  made  to  compress 
the  heart  and  great  bloodvessels  with  such  force  as  actually 
to  stop  the  circulation. 

The  diaphragm,  as  the  most  yielding  portion  of  the  chest- 
wall,  is  the  jDart  most  influenced  by  pulmonary  suction. 
The  pressure  on  its  abdominal  surface  is  almost  always 
positive.  Hence,  in  its  passive  state,  the  diaphragm  is 
sucked  upwards  into  the  dome-shaped  form,  and  every 
contraction  and  consequent  flattening  of  it  has  to  over- 
come pulmonary  elasticity. 

When  the  deepest  possible  inspiration  is  taken,  the 
diaphragm  tends  to  be  more  than  usually  elevated,  owing 
to  the  increase  in  pulmonary  suction  (see  p.  59). 

The  elastic  force  exerted  by  the  lungs  at  the  end  of  an 
ordinary  expiration  is  equal  to  a  column  of  from  5  to  7  mm. 

there  is  no  physical  union  with  them.  They  do  indeed  drag  upon  the 
^■isceral  pleur*,  but  not  upon  other  parts — the  chest-walls,  for  instance. 
These  latter  are  not  drawn  inwards :  they  are  driven  inwards,  or  tend 
to  be  so,  by  the  atmospheric  pressure,  which  is  greater  than  the  pres- 
sure which  the  lungs  exert  upon  the  chest-walls. 

*  The  negative  pressure  in  the  pleurae  and  pericardium  can  be 
estimated  by  introducing  into  one  of  these  cavities  a  cannula  con- 
nected by  means  of  a  rigid  tube  with  a  manometer,  care  being  taken 
to  exclude  the  air.  It  may  also  be  shown  that  the  intra-thoracic 
portion  of  the  cesophagus  is  similarly  affected  by  pulmonary  suction, 
and  that  this  increases  with  every  inspiration. 

Leyden  and  Quincke  have  tested  the  negative  pressure  in  the  pleurit 
after  drawing  off  a  pleuritic  effusion.  The  former  has  shown  it  to 
be  as  low  as  -42  mm.  Hg  during  a  deep  inspiration,  and  the  latter  as 
low  as  -  40  mm.  Hg. 


THE    ELASTICITY    OF    THE    LUNGS  3 

of  mercury,  for  if  after  death,  when  the  chest  is  in  a  position 
of  ordinary  expiration,  a  manometer  is  fixed  in  the  trachea 
the  mercury  rises  to  about  this  height  on  the  chest-walls 
being  punctured  and  the  lungs  thus  permitted  to  collapse. 
When  the  chest  is  forcibly  inflated  to  the  position  of  ordinary 
inspiration,  the  mercury  rises  to  about  10  mm.,  and  the  rise 
increases  to  30  mm.  if  the  chest  is  distended  to  the  position 
of  extraordinary  inspiration.  At  the  end  of  an  extra- 
ordinary expiration  elastic  force  is  absent,  the  lungs  then 
being  actually  smaller  than  after  removal  from  the  body. 

Hence,  the  elastic  force  or  suction  exerted  by  the  lungs 
under  varying  degrees  of  expansion  is  as  follows  : 

At  the  end  of  an  extraordinary  expiration,  0. 

,,  ,,  ordinary  ,,  5  mm.  Hg. 

,,  ,,  ,,  inspiration,  10         ,, 

,,  ,,  extraordinary         ,,         30         ,, 

The  elastic  force  exerted  by  the  bronchial  muscles,  when 
contracted,  is  estimated  at  from  1  to  2  mm,  Hg. 

Other  aspects  of  pulmonary  suction  have  now  to  be  con- 
sidered. 

All  the  tissues  of  the  body  tend  to  become  less  elastic 
with  advancing  years.  It  is,  for  instance,  owing  to  loss  of 
elasticity  that  the  skin  becomes  wrinkled  with  age ;  it  gets 
permanently  stretched,  and,  no  longer  tightly  adapting  itself 
to  the  underlying  structure,  is  thrown  into  folds.  As  with 
the  skin,  so  also  with  the  lungs.  Their  elasticity,  and 
consetjuently  the  suction  they  exert,  diminishes  with  ad- 
vancing years.  In  the  senile  lung  it  is  comparatively  small. 
Pulmonary  elasticity  diminishes  much  more  rapidly  in 
some  cases  than  in  others,  so  that  while  in  one  we  may 
find  prematurely  senile  lungs  at  fifty,  in  another  elasticity 
may  be  well  preserved  at  seventy.  It  may  also  be  diminished 
by  disease.     All  organic  diseases  of  the  lungs — pneumonia, 

1—2 


4  EESPIRATOEY    EXERCISES 

bronchitis,  phthisis — diminish  it.  In  emphysema  the  dimi- 
nution is  a  characteristic  feature,  and  plays  a  prominent 
part  in  its  pathology.  Elasticity  is  also  probably  always 
diminished  in  protracted  fever  ;  Cohnheim  finds  it  absent 
in  typhoid ;  Perls  has  fouiid  it  diminished  in  typhoid, 
typhus,  and  diphtheria ;  and  both  have  noticed  its  loss  in 
phosphorus-poisoning. 

Undue  stretching  of  the  pulmonary  alveoli  is  another 
very  potent  cause  of  its  diminution  or  entire  loss.  It  is  in 
this  way  that  effort,  such  as  coughing  and  lifting  weights, 
diminishes  elasticity.  Chronic  dyspnoea  diminishes  it  in  the 
same  way — namely,  by  causing  overexpansion  of  the  lungs 
— and  hence  also  the  injurious  tendency  of  all  exercises 
causing  breathlessness,  such  as  running  rapidly  upstairs, 
swimming  for  a  long  time  under  the  water,  etc.  (see 
pp.  93,  94). 

It  is  seldom,  however,  that  pulmonary  elasticity  is  so 
completely  lost  as  to  do  away  with  all  suction — in  fact, 
probably  in  the  most  advanced  cases  of  emphysema  only. 
When  a  portion  of  the  lung  is  solidified,  as  in  pneumonia, 
it  necessarily  loses  all  elasticity,  and  therefore  all  suction. 
Post-mortem  examination  gives  no  evidence,  however,  that 
the  parts  thus  solidified  press  upon  the  chest-walls,  as  from 
their  distension  we  might  perhaps  expect  them  to  do.  This 
is  because  the  thorax  over  the  affected  region  expands,  and 
I  have  no  doubt  that  Sir  James  Douglas-Powell  is  right  in 
attributing  this  expansion  to  loss  in  pulmonary  elasticity. 
He  holds  that  '  as  the  inflamed  lung  increases  in  bulk, 
the  thoracic  wall  retreats,'  owing  to  the  removal  of  pul- 
monary elasticity,  which  normally  causes  the  ribs  to  be 
sucked  in  Jjeyond  the  neutral  point. ''■  I  would  suggest  that 
a  more  important  factor  even  than  this  is  the  overaction  of 
the  inspiratory  muscles.  This  overaction  necessarily  results 
*  '  Diseases  of  tlie  Lungs  and  Pleura;,'  4th  edit.,  p.  19. 


TEIE    ELASTICITY    OF   THE    LUNGS  5 

from  the  diminution  of  suction,  and  is,  moreover,  predisposed 
to  by  dyspna'a  (see  Chapter  on  Dyspncea). 

Effusion  of  gas  or  liquid  into  the  pleura  diminishes 
pulmonary  suction,  the  stretched  elastic  fibres  of  the  lung 
becoming  more  and  more  lax  as  the  effusion  increases  and 
the  lung  shrinks,  and  it  continues  to  diminish  until  the 
shrinkage  of  the  lung  has  proceeded  to  the  point  at  which 
the  pulmonary  fibres  are  no  longer  stretched,  when  it  com- 
pletely disappears.  The  continuance  of  effusion  beyond 
this  point  causes  the  pressure  in  the  pleura  to  become 
increasingly  positive.  In  one  case  of  hydrothorax  Ley  den 
found  the  pressure  of  the  pleural  fluid  to  be  28  mm.  Hg,  and 
in  a  case  of  pneumothorax  he  found  the  pressure  of  air  in 
the  pleura  to  vary  between  5  and  10  mm.  Hg.  In  pleuritic 
effusion  the  heart  is  displaced  to  the  opposite  side  before 
the  diaphragm  is  thrust  downwards ;  for  directly  the  pul- 
monary suction  of  the  affected  side  diminishes — and  this 
occurs  at  the  very  beginning  of  the  effusion — the  heart  will 
be  drawn  over  by  the  greater  suction  of  the  opposite  side, 
but  the  pressure  on  the  abdominal  aspect  of  the  diaphragm 
being  positive,  it  will  not  be  until  the  pleural  pressure 
becomes  still  more  positive  that  the  diaphragm  will  be 
thrust  downwards.  Hence,  as  Douglas-Pow'ell  observes, 
'  displacement  downwards  of  the  abdominal  viscera  is  a 
late  phenomenon  in  pleuritic  effusion,'*  and  'the  stomach 
note  may  be  obtained  at  the  sixth  rib  in  the  nipple  line  in 
the  presence  of  a  large  effusion  on  that  side.' 

In  gaseous  effusion  into  the  pleura  the  heart  is  imme- 
diately sucked  over  to  the  unaffected  side,  but  the  pressure 
cannot  be  sufficiently  positive  to  displace  the  diaphragm 
until  the  occurrence  of  considerable  liquid  effusion. 

Just  as  pulmonary  suction  diminishes  as  the  elastic  fibres 
of  the  lungs  become  more  and  more  lax,  so  on  the  other 
*  Oi).  cit.,  p.  106. 


6  RESPIRATORY    tXERCISES 

hand,  does  it  increase  the  more  these  fibres  are  stretched, 
for  the  greater  this  stretching,  the  more  do  the  lungs 
strive  to  retract  from  the  chest- wall  and  other  adjacent 
structures.  Hence,  suction  is  greater  during  inspiration 
than  expiration.  The  lung  presses  against  its  contiguous 
structures  with  a  force  equal  to  the  pressure  of  the  air  in 
the  air- vesicles  less  the  amount  of  elastic  force  these  latter 
exert  upon  their  contained  air.  The  alveolar  air-pressure 
at  the  end  of  an  ordinary  inspiration  is  about  1  mm.  Hg 
less  than  the  atmospheric  pressure — i.e.,  59  mm.  Hg — 
and  the  alveolar  elastic  force  is  then  about  10  mm.  Hg. 
Hence,  at  the  end  of  an  ordinary  inspiration  the  lungs 
jDress  upon  the  surrounding  structures  with  a  force  equal  to 
749  mm.  Hg,  this  being  11  mm.  Hg  less  than  the  atmo- 
spheric pressure.  At  the  end  of  an  ordinary  expiration  the 
alveolar  air-pressure  is  about  2  mm.  Hg  more  than  the 
atmospheric  pressure — i.e.,  762  mm.  Hg — and  the  alveolar 
elastic  force  about  5  mm.  Hg.  Consequently,  the  lungs 
then  press  upon  surrounding  structures  with  a  force  equal 
to  762—  5  =  757  mm.  Hg,  this  being  3  mm.  Hg  less  than  the 
atmospheric  pressure. 

It  is  therefore  clear  that  during  ordinary  breathing  the 
structures  contiguous  to  the  lungs  are  subject  to  suction 
which  increases  with  every  inspiration. 

At  the  end  of  an  extraordinary  inspiration  the  negative 
pressure  on  the  extra-pulmonary  structures  is  considerable, 
while  at  the  termination  of  an  extraordinary  c-xpiration  the 
pressure  may  become  very  decidedly  positive.  The  effect 
of  vigorous  inspiration  and  expiration  is  still  more  pro- 
nounced when  the  entrance  to  the  respiratory  tract  is 
closed.  Thus,  a  vigorous  inspiration  with  completely 
closed  mouth  and  nostrils  may  reduce  the  pressure  to 
-70  mm.  Hg,  or  further.*     This  is  known  as  '  Miiller's 

*  According  to  Ocrtel,  it  may  fall  as  low  as  -  100  mm.  Hg.  (Von 
Ziemssen's  '  Handbook  of  General  Therapeutics,'  vol.  iii.,  p.  577). 


THE    ELASTICITY    OF   THE    LUNGS  7 

experiment.'  The  diminution  of  pressure  is  essentially  due 
to  rarefaction  of  the  intra-pulmonary  air,  and  not  simply,  as 
in  inspiration  with  open  glottis,  to  stretching  of  the  elastic 
lung.  On  the  other  hand,  a  forcible  expiration  with  closed 
mouth  and  nostrils,  after  the  method  used  by  aurists  to 
inHate  the  mid-ear,  may  raise  the  intra-pulmonary  pressure 
120  mm,  Hg  above  that  of  the  atmosphere,  the  heart  and 
great  bloodvessels  and  intra-pulmonary  vessels  being  in 
this  way  so  firmly  compressed  as  seriously  to  interfere  with 
the  circulation.  This  is  known  as  '  Valsalva's  experiment.' 
A  similar  effect  is  produced  by  all  forms  of  effort  when  a 
powerful  expiration  is  made  with  partially  or  completely 
closed  glottis. 

The  intra-pulmonary  air-pressure  may  in  a  similar  way 
be  modified  by  causing  the  air  which  is  inhaled,  or  that 
into  which  the  expired  air  passes,  to  be  condensed  or 
rarefied. 

Means  for  maintaining  Pulmonary  Elasticity. — Since  loss 
of  pulmonary  elasticity  induces  many  evils,  foremost  among 
which  is,  as  we  have  seen,  emphysema,  it  is  of  the  greatest 
importance  to  preserve  the  elasticity  as  much  as  possible. 
To  this  end  we  should  endeavour  to  check  the  advent  of 
premature  senility  by  urging  the  individual  to  lead  a 
healthy,  temperate  life;  the  lungs  should  be  carefully 
protected  from  bronchitis,  pneumonia,  and  other  diseases  ; 
coughing,  the  blowing  of  wind  instruments,  straining  at 
stool,  and  all  other  muscle-efforts  with  fixed  thorax,  should 
be  avoided  ;  and  special  means  should  be  adopted  to  pre- 
vent overdistension  of  the  thorax  from  dyspnoea.  The 
methods  given  in  Chapter  XXI.  for  increasing  and  pre- 
serving the  mobility  of  the  thoracic  cage  are  also  useful  in 
maintaining  the  elasticity  of  the  lungs. 

It  is  by  no  means  impossible  to  avoid  the  fixation  of  the 
chest  which  accompanies  effort.     The  fixation  is  eftected  by 


8  RESPIRATORY    EXERCISES 

closure  of  the  glottis,  and  one  should  therefore  get  mto  the 
habit  of  always  keeping  the  glottis  open  during  muscular 
exertion,  for  under  these  circumstances  it  is  impossible  to 
raise  the  intra-pulmonary  pressure  unduly,  and  thus  dis- 
tend the  alveoli  to  a  dangerous  degree.  To  take  a  par- 
ticular instance  :  much  injury  may  be  done  to  the  lungs 
by  habitual  strainmg  at  stool,  but  this  may  be  entirely 
avoided  by  never  allowing  the  glottis  to  be  closed  during 
defsecation. 


CHAPTER  II. 

INTRA-ABDOMINAL  TENSION— FUNCTIONS  OF  THE 
ABDOMINAL  MUSCLES. 

The  pressure  in  the  abdominal  cavity  is  under  normal  con- 
ditions positive,  i.e.,  greater  than  the  atmospheric  pressure, 
wherefore  the  abdominal  contents  press  against  their  con- 
taining walls,  tending  to  l)ulge  them.  When,  as  sometimes 
happens,  the  mternal  pressure  is  negative,  these  walls  are 
sucked  in. 

Positive  mtra-abdominal  pressure  plays  a  not  unimportant 
part  in  exph-ation.  The  diaphragm  when  in  a  state  of  rest 
lies  high,  the  pressure  on  its  under  surface  being  positive, 
and  that  on  its  upper  surface  negative.  When  its  muscle- 
fibres  contract,  it  flattens  out,  and  in  so  doing  it  has  to  work 
against  the  intra-abdominal  pressure,  which  it  increases. 
The  abdominal  viscera  constitute,  so  to  speak,  an  elastic 
buffer,  which  is  compressed  with  every  descent  of  the 
diaphragm,  and  by  its  recoil  drives  the  diaphragm  up  at 
the  end  of  inspiration. 

This  positive  intra-abdominal  pressure  depends  upon  the 
pressure  of  the  atmosphere  upon  the  yielding  abdominal 
walls,  and  also  upon  the  contraction  of  the  abdominal 
muscles.  Thus,  it  is  greatest  in  muscular  men,  while  it 
is  least  in  multiparous  women  with  flaccid  abdominal  walls. 

The  fact  that  the  abdominal  walls  are  yielding  and  not 
rigid,  renders  it  difficult  to  get  a  negative  intra-abdominal 


10  RESPIRATORY   EXERCISES 

pressure,  owing  to  the  pressure  of  the  surrounding  atmo- 
sphere. Under  certain  circumstances,  however,  it  is  negative. 
Thus,  when  a  deep  costal  inspiration  is  taken,  the  diaphragm 
is  sucked  upwards  by  pulmonary  suction,  and  the  abdo- 
minal walls  are  sucked  inwards,  this  suction  being  increased 
if  the  breath  is  taken  with  closed  glottis.  The  effect  of  this 
upward  movement  of  the  diaphragm  upon  the  pressure 
within  the  abdomen  is  comparable  to  the  pulling  out  of  the 
piston  of  an  air-pump.  It  is  said  that  the  intra-abdominal 
tension  in  some  women  is  habitually  negative,  a  phenomenon 
very  difficult  to  account  for,  except  on  the  assumption  that 
it  is  produced  by  pulmonary  suction. 

Intra-abdominal  tension  is  increased  by  forcible  con- 
traction of  the  abdominal  muscles,  especially  if  the  glottis 
is  partly  or  completely  closed,  as  in  cough  or  muscle- 
effort — straining  at  stool,  for  instance.  In  the  latter  case 
the  diaphragm  is  fixed,  and  the  contracting  abdominal 
muscles  compress  the  underlying  structures  with  great 
force. 

Inasmuch  as  intra  -  abdominal  tension  is  greater  in 
muscular  men  than  in  women  with  flabby  abdominal  walls, 
abdominal  operations  are  more  difficult  in  the  former  than 
in  the  latter.  In  the  very  muscular  the  intestines  are 
forcibly  driven  out  directly  the  cavity  is  opened,  and  the 
hand  when  introduced  may  be  so  firmly  grasped  as  to 
render  exploration  of  the  viscera  impossible,  without  push- 
ing anaesthesia  to  its  limit.* 

The  degree  to  which  the  abdominal  muscles  compress 
the  underlying  viscera  is  largely  determined  by  occupation. 
Thus,  as  Bruce  Clarke  points  out,  the  abdomen  of  a  fisherman 
is  hard  and  flat,  and  may  remain  so,  even  up  to  advanced 
age,  a  circumstance  he  attriljutes  mainly  to  the  eft'ect  of 

*  See  '  On  Some  Effects  of  a  Lack  of  Muscular  Development,' 
W.  Bruce  Clarke,  Brit.  Med.  Jour.,  1896,  vol.  ii.,  p.  1493. 


INTRA-ABDOMINAL    TENSION  11 

rope-hauling  in  developing  these  muscles  ;  he  also  calls 
attention  to  the  marked  influence  of  this  occupation 
in  diminishing  abdominal  obesity.  It  may  be  observed, 
in  passing,  that  all  muscle  exercises  do  not  cause  fat  to 
disappear  at  the  same  rate  all  over  the  body.  The  fat  tends 
to  be  absorbed  chiefly  in  the  neighbourhood  of  the  muscles 
most  actively  employed.  Thus,  if  a  stout  man  takes  to 
fencing,  the  loss  of  fat  takes  place  chiefly  about  the  chest, 
and  similarly,  rope-hauling,  which  calls  the  abdominal 
muscles  into  active  play,  is  especially  calculated  to  remove 
fat  from  the  belly. 

The  chief  causes  of  abdominal  flaccidity,  with  its  con- 
sequent low  intra-abdominal  tension,  are  :  a  sedentary  life, 
the  wearing  of  stays  (which  prevent  the  free  play  of  the 
abdominal  muscles),  and  the  distension  of  the  abdominal 
walls  produced  by  repeated  pregnancies  and  by  ascitic  and 
adipose  accumulations.  Thus,  the  abdomen  of  a  person 
who,  from  being  very  stout,  has  become  rapidly  thin,  is 
very  apt  to  be  flaccid.  Intra-abdominal  tension  is,  of 
course,  also  diminished  by  paralysis  of  the  abdominal 
muscles,  as  in  myelitis  and  in  idiopathic  muscle-atrophy,  of 
which  I  have  a  good  example  at  present  under  observation. 

But  the  tension  within  the  abdomen,  though  mainly 
dependent  on  the  contraction  of  the  abdominal  walls,  may 
be  increased  by  other  conditions.  Thus,  the  pressure 
within  the  stomach  and  intestines  varies  from  hour  to  hour 
even  in  health.  Often  it  is  negative,  but  it  is  frequently  also 
positive ;  e.(j.,  after  a  heavy  meal  it  may  be  very  decidedly 
positive,  and  may  cause  a  considerable  bulging  of  the  upper 
part  of  the  belly.  (It  is  this  positive  gastric  pressure  which 
is  the  essential  factor  in  causing  dilated  stomach.)  Again, 
the  stomach  and  intestines  may  be  distended  by  flatus, 
and  intra-abdominal  tension  is  then  much  augmented,  the 
abdominal  walls  often  being  stretched  as  tight  as  a  drum. 


12  RESPIRATORY   EXERCISES 

Ascitic  and  other  dropsical  accumulations  and  abdominal 
tumours  also  greatly  increase  it.  Quincke  found  the  average 
intra-peritoneal  pressure  in  ascites  to  be  25  mm.  Hg.  A 
full  bladder  increases  abdominal  tension.  A  large  deposit 
of  fat  M'ithin  the  belly  favours  high  tension. 

Secondary  Effects  of  Low  Intra-abdominal  Tension. — A 
fairly  high  intra-abdominal  tension  is  essential  to  health. 
"When  the  abdominal  muscles  fail  to  maintain  adequate 
pressure  on  the  underlying  parts  several  evils  result : 

(a)  Dislocation  of  the  abdominal  viscerc  is  apt  to  occur. 
Bruce  Clarke  lays  great  stress  upon  the  part  taken  by  the 
abdominal  muscles  in  maintaining  the  underlying  viscera 
in  their  proper  position.  When  the  abdominal  walls  are 
habitually  flaccid,  all  the  viscera,  including  the  liver,  spleen, 
and  pancreas,  tend  to  travel  downwards.  This  is  a  potent 
cause  of  floating  kidney,  which  is  never  met  with  in  those  with 
well-developed  abdominal  walls.  Visceral  descent  also  causes 
lengthening  of  the  mesentery  and  the  '  bulging  '  abdomen, 
and  it  leads  to  certain  symptoms  very  common  in  women. 
'  There  is  pain  in  the  back  and  a  continued  sense  of  weari- 
ness. Gastric  symptoms  are  prominent ;  the  most  con- 
spicuous are  a  sense  of  burning  in  the  epigastric  region, 
vomiting,  pain,  loss  of  appetite,  distress  after  food,  and 
more  or  less  dyspepsia.  .  .  .  The  symptoms  are  more  or 
less  relieved  by  pressing  upon  the  lower  parts  of  the 
abdomen  with  the  two  hands,  or  by  the  wearing  of  a 
supporting  belt.  Many  patients  are  unable  to  move  about 
until  they  have  adjusted  their  supports  or  bands.'* 

{b)  Constipation  is  induced.  Increase  of  intra-abdominal 
tension  is  an  important  factor  in  defecation,  and  when  the 
abdominal  muscles  are  weak  they  are  incapable  of  effecting 
the  necessary  degree  of  tension,  and  defalcation  becomes 
difficult. 

*  Treves,  Brit.  Med.  Jour.,  1896,  vol.  i.,  p.  1. 


INTRA-ABDOMINAL    TENSION  13 

(c)  There  is,  as  Leonard  Hill  has  so  well  shown,  a  tendency 
for  the  blood  to  accumulate  in  the  splanchnic  area,  with 
consequent  syncope.  The  great  sphinchnic  veins,  Hke  tlie 
veins  in  general,  are  very  susceptible  to  pressure,  and 
the  amount  of  blood  they  contain  is  largely  dependent 
upon  the  pressure  the  abdominal  walls  exert  upon  them. 
Thus,  a  large  quantity  of  blood  may  be  squeezed  out  of 
them  by  simply  pressing  the  belly  firmly  with  the  hand. 
Now,  owing  to  the  influence  of  gravity,  the  blood  is  very 
apt  to  accumulate  in  the  splanchnic  veins  in  the  upright 
position  ;  and  it  is  not,  therefore,  surprising  that  women, 
who  so  frequently  suffer  from  abdominal  flaccidity  from 
the  combined  influences  of  child-bearing,  tight-lacing,  and 
bodily  inactivity,  should  be  prone  to  faintness  or  actually  to 
faint,  especially  when  the  stays  are  removed.  I  have  myself 
known  of  more  than  one  instance  of  a  woman  fainting 
upon  the  removal  of  her  stays.  The  same  thing  may 
happen,  and  for  a  similar  reason,  when  a  large  quantity 
of  ascitic  fluid  is  suddenly  removed,  or  even  after  emptying 
the  bladder  in  the  upright  position — especially,  as  Lauder 
Brunton  observes,  if  a  patient  with  aortic  regurgitation 
suddenly  gets  out  of  bed  to  do  this.  Stays  correct  the 
evil  in  question  while  they  are  on,  but  the  most  efficient 
stays  are  natural  ones,  in  the  shape  of  well-developed 
abdominal  muscles.  Li  the  normal  subject  the  transversales 
in  the  upright  position  keep  the  anterior  and  posterior 
abdominal  walls  in  firm  contact,  and  prevent  the  undue 
accumulation,  through  gravity,  of  blood  in  the  splanchnic 
area.  Such  an  accumulation,  with  its  consequent  faintness, 
often  occurs  when  a  patient  first  gets  up  after  having  lain 
in  bed  for  a  long  time.  Leonard  Hill  attributes  this  to 
failure,  through  disuse,  of  the  regulating  vaso-motor 
action  of  the  splanchnic  vessels,  which  normally  com- 
pensates for  the  effects  of  gravity  in  the  upright  position  ; 


14  RESPIRATORY   EXERCISES 

but  I  think  it  may  also  in  part  be  due  to  ^Yeakness  of  the 
abdominal  muscles  consequent  upon  disuse  and,  it  may 
be,  disease.  In  prolonged  fever,  for  instance,  the  nutrition 
of  the  muscles  always  suffers. 

Since  the  above  ^Yas  written,  Hill  has  published,  in  conjunc- 
tion with  Harold  Barnard,  a  second  paper  on  the  influence  of 
gravity  on  the  circulation,*  in  which  the  part  played  by  the 
abdominal  muscles  in  preventing  the  gravitation  of  blood 
into  the  splanchnic  veins  is  worked  out.  They  show  that 
when  the  splanchnic  vaso-motor  mechamsm  is  intact  it 
suffices  of  itself  to  prevent  this,  but  that  when,  as  by  section 
of  the  splanchnic  nerves,  this  mechanism  is  destroyed,  a 
second  mechanism  comes  into  play  in  the  shape  of 
'  expiratory  compressions  of  the  abdomen  occurring  simul- 
taneously with  inspiratory  thoracic  suctions,'  the  former 
squeezing,  and  the  latter  sucking,  the  blood  out  of  the 
splanchnic  pool.  This  enables  the  circulation  to  be  carried 
on,  though  not  so  efficiently  as  before.  We  may  speak 
of  this  as  the  respiratory  mechanism.  That  the  latter 
mechanism  is  not  so  efficient  in  compensation  as  the  former 
is  shown  by  the  fact  that  the  effects  of  gravity  may  be 
entirely  compensated  for  after  the  injection  of  curare,  which 
paralyzes  the  muscles  and  thus  destroys  the  respiratory 
mechanism.  This  quite  harmonizes  with  one's  clinical 
experience.  We  sometimes  meet  with  patients  in  whom 
this  mechanism  cannot  operate,  but  who,  nevertheless,  are 
able  to  assume  the  vertical  posture  without  fainting.  Such 
are  women  with  lax,  atrophied  abdominal  walls  and  fixed 
emphysematous  chests  (in  which,  therefore,  thoracic  suction 
is  practically  absent).  The  ability  of  such  to  stand  without 
fainting  implies,  of  course,  a  vigorous  state  of  the  splanch- 
nic vaso-motor  system. 

Both  mechanisms  may  be  destroyed  by  dividing  the  cord 

*  Jour.  I'hijH.,  vol.  xxi.,  p.  323. 


INTRA-ABDOMINAL   TENSION  15 

at  the  first  dorsal  vertebra.  If  the  animal  operated  on  l)e 
then  held  vertically  with  the  head  up,  the  whole  of  the  blood 
collects  in  the  splanchnic  veins,  and  *  the  empty  heart  con- 
tinues vainly  to  beat.'  On  compressing  the  belly,  however, 
the  blood  is  squeezed  into  the  heart,  and  the  circulation  is 
re-established. 

{(I)  The  accelerating  influence  of  the  diaphragmatic 
movements  on  the  circulation  is  interfered  with.  These 
movements,  as  will  be  shown  in  Chapter  XIII. ,  play  an 
important  part  in  assisting  the  abdominal  circulation  by 
rhythmically  increasing  intra-abdominal  tension  ;  but  when 
the  abdominal  walls  are  \evy  flaccid,  the  descent  of  the 
diaphragm  will  have  little  or  no  effect  upon  the  tension, 
and  consequently  on  the  flow  of  blood  in  the  intra-abdominal 
veins. 

(In  the  above  experiment  of  dividing  the  cord,  the 
diaphragm  continues  to  act,  inasmuch  as  the  phrenics 
arise  above  the  section.  By  its  action  it  is  able  to  increase 
thoracic  suction  slightly,  and  to  squeeze  a  small  quantity 
of  blood  out  of  the  abdominal  veins.  The  latter  action  is, 
however,  infinitesimal,  owing  to  the  parah^zed  state  of  the 
abdominal  muscles,  which  prevents  the  abdominal  pressure 
from  being  raised,  except  very  slightly,  by  descent  of  the 
diaphragm.) 

The  Action  of  the  Abdominal  Muscles. — The  action  of  the 
transversalis  abdominalis  has  been  to  «  l^ygp  pv^pnt  ^ver- 
looked  by  anatomists.  The  superior  fibres,  stretching  as 
they  do  across  the  costal  arch,  tend  to  narrow  it,  and  thus 
to  favour  expiration.  The  middle  fibres,  taking  their  origin 
posteriorly  from  the  lumbar  fascia  and  stretching  forwards 
towards  the  mid-abdomen,  by  their  strong  contraction 
bring  the  anterior  and  posterior  abdominal  walls  in  this 
region  into  firm  contact,  thus  shutting  ofi'  the  upper  part 
of  the  abdominal  cavity  from  the  lower.     This  contraction 


16  RESPIRATORY   EXERCISES 

leads  to  considerable  compression  of  the  kidneys,  and  it 
does  not  seem  improbable  that  the  normal  healthy  tone 
of  the  transversalis  has  a  good  deal  to  do  with  keeping 
the  kidneys  in  their  normal  position  ;  contraction  of  the 
middle  fibres  also  presses  the  stomach,  liver,  and  intestines 
firmly  up  against  the  diaphragm,  and,  by  interfering  with 
the  descent  of  this  structm'e,  enables  it  to  expend  its 
energy  in  elevating  the  ribs  rather  than  in  flattening  itself. 
The  upper  and  middle  portions  of  the  transversalis  may  be 
said  to  constitute  'Nature's  stays.' 

The  lowermost  fibres  springing  from  the  iliac  crests  and 
Poupart's  ligaments  cause  by  their  contraction  a  flattening 
of  the  lower  abdomen. 

The  most  transversely  disposed  fibres  of  the  internal 
oblique  have  a  similar  action  to  the  middle  fibres  of  the 
transversalis,  and  retract  the  mid-abdomen. 

All  those  fibres  of  the  external  and  internal  oblique 
which  are  attached  to  the  ribs  are  powerful  expirators, 
and  are  capable  of  depressing  the  thorax  with  great  force. 
In  this  way  the  diaphragm  is  carried  downwards,  and  the 
abdominal  cavity  being  thus  diminished  in  height,  the 
anterior  walls  tend  to  bulge  forwards. 

The  recti  are  very  powerful  muscles.  They  depress  the 
sternum  and  ribs.  Each  rectus  is  capable  of  acting  more 
or  less  independently  of  its  fellow,  and  each  fasciculus  also 
has  apparently  independent  action,  and  may  contract 
independently  in  order  to  protect  any  painful  tissue 
underlying  it.  These  muscles  play  an  important  part  in 
rendering  the  belly  flat  and  in  supporting  the  under- 
lying viscera. 

Method  of  testing  the  Tone  of  the  Abdominal  Muscles. — 
Whenever  the  tone  of  the  abdominal  muscles  is  defective, 
we  can  improve  the  condition  of  our  patient  by  restoring 
them  to  a  healthy  state.     The  result  of  treatment  directed 


INTRA-ABDOMINAL    TENSION  17 

to  this  end  is  sometimes  quite  remarkable.  In  all  cases, 
therefore,  where  we  have  reason  to  suspect  undue  flaccidity 
of  the  abdominal  walls,  we  should  make  a  careful  inspection 
of  the  abdomen.  Sometimes  the  skin  is  so  loose,  the  walls 
so  flaccid,  that  it  is  quite  easy  to  inspect  and  to  palpate  the 
various  underlying  organs.  In  such  cases  a  wide  interval 
can  generally  be  felt  between  the  recti.  When,  however, 
as  often  happens,  the  actual  condition  of  the  muscles  is 
concealed  by  a  copious  deposit  of  fat,  and  the  abdominal 
wall  appears  normal,  even  though  its  muscles  be  flabby 
and  wasted,  we  should  ask  the  patient  gradually  to  raise 
the  body  while  lying  supine,  or  to  bear  down  forcibly, 
and  we  shall  then,  by  the  feel  of  the  muscles  under  the 
skin,  be  able  to  estimate  their  condition  fairly  accurately. 

When  forming  an  opinion  upon  the  state  of  the  abdominal 
walls,  we  must  bear  in  mind  that  normally  they  are  con- 
siderably influenced  by  age  and  sex.  In  infants  and  young 
children  the  belly  bulges  very  much,  therein  displaying  a 
characteristic  of  man's  quadrumanous  ancestry,  protrusion 
of  the  belly  being  a  well-marked  feature  in  the  anthropoidal 
apes.  A  further  characteristic  of  the  young  child's  anterior 
abdominal  wall  is  the  separation  of  the  recti.  If,  for 
instance,  we  observe  the  belly  of  an  infant  while  it  is  lying 
on  its  back  and  endeavouring  to  sit  up,  we  shall  perceive  a 
spindle-shaped  swelling  along  the  region  of  the  linea  alba. 
This  is  due  to  the  protrusion  of  the  fibrous  membrane 
uniting  the  two  recti,  owing  to  heightened  intra-abdominal 
tension.  It  is  especially  pronounced  in  infants  who  suffer 
from  chronic  flatulent  distension — a  common  complaint 
with  them.  In  such,  the  abdomen  is  more  than  usually 
prominent  and  the  interval  between  the  recti  abnormally 
wide. 

As  the  child  gets  older  the  belly  flattens,  and  the  recti 
approach  one  another,  and  it  is  not  until  the  belly  has 

2 


18  RESPIRATORY    EXERCISES 

attained  the  maximum  flatness  that  the  recti  become  fixed 
in  close  approximation,  the  fibrous  membrane  between 
them  becoming  so  narrow  that  it  can  no  longer  be  pro- 
truded. This  takes  place,  according  to  my  observations,  at 
about  the  third  or  fourth  year.* 

Accompanying  this  abdominal  flattening  is  a  similar 
flattening  of  the  thorax,  which,  like  the  belly,  is  round 
in  the  infant  and  the  anthropoids,  and  no  doubt  the  process 
has  in  each  case  a  similar  object,  i.e.,  the  maintenance 
of  the  vertical  position  by  keeping  the  centre  of  gravity 
vertically  above  the  narrow  basis  of  support  afforded  by  the 
feet. 

The  abdomen  contmues  flat  in  the  male,  if  he  remains 
in  good  condition,  until  the  end  of  life ;  but  in  the  female 
a  considerable  deposit  of  subcutaneous  fat  occurs  in  the 
anterior  abdominal  wall  at  puberty,  so  that  in  the  normal 
adult  female  the  belly  is  rounded. 

Exercises  for  strengthening  the  abdominal  muscles  are 
given  in  Chapter  XX. 

*  I  have,  however,  often  noticed  the  protrusion  referred  to  aboVe 
some  time  after  the  beUy  has  attained  its  maximum  degree  of  flatness. 


CHAPTER  III. 

THE  ELASTICITY  OF  THE  THORACIC  CAGE. 

I  USE  the  term  '  thoracic  cage '  to  denote  the  chondro- 
osseous  walls  of  the  '  thorax,'  this  latter  term  signifying  not 
only  the  parietes  of  the  chest,  but  its  contents  also. 

The  thoracic  cage  is  elastic,  i.e.,  its  several  parts,  in- 
cluding the  ribs,  cartilages,  sternum,  spine,  and  also  the 
clavicles  (for  they  m  a  measure  belong  to  it),  are  capable  of 
being  bent,  and  of  springing  back  to  their  original  positions 
when  the  bending  force  has  ceased  to  act. 

John  Hutchinson  measured  the  elasticity  of  the  thoracic 
cage  by  driving  air  into  the  lungs  with  sufficient  power  to 
rupture  them,  and  then  noticing  the  height  to  which  the 
returning  air  was  able  to  lift  a  column  of  mercury.  In  one 
case  he  found  that  by  forcing  in  the  amount  of  air  which 
corresponded  to  the  '  vital  capacity '  of  the  individual — 
namely,  200  cubic  inches — the  returning  air  was  able  to 
raise  4" 5  cubic  inches  of  mercury ;  therefore  the  complete 
expansion  of  the  chest  in  that  case  '  must  have  demanded  a 
muscular  power  equal  to  resisting  an  elastic  force  com- 
mensurate to  4i  inches  of  mercury,  upon  every  square  inch  of 
his  chest  which  was  moved  or  expanded  by  muscle.'* 
Hutchmson  further  calculated  that  this  man,  in  taking  a 
deep  inspiration,  must  have  exerted  a  muscular  power 
capable  of  raising  450  lbs. ;  and  in  another  case  he  found 
that  the  thoracic  elasticity  must  have  equalled  1,000  lbs. 

*  Med.  Chir.  Trans.,  1846.  p.  207. 

2—2 


20  RESPIRATORY    EXERCISES 

The  elasticity  of  the  ribs,  cartilages,  and  sternum  is 
greatest  in  early  life.  Hence,  in  young  children  the  thorax  is 
very  easily  compressed.  With  advancing  years,  especially  in 
old  age,  these  structures  tend  to  become  increasingly  rigid 
from  the  deposit  of  lime  salts  in  them,  and  we  therefore 
frequently  find  the  costal  cartilages  calcified.  Humphrey 
regards  this  change  as  a  morbid  rather  than  a  normal 
senile  change.  He  points  out  that  the  costal  cartilages  of 
old  people  can  often  be  as  readily  cut  with  the  knife  as  those 
of  the  young,  and  he  found  that  in  one  man  a  hundred 
years  old  they  contained  no  excess  of  mineral  matter. 

Calcification  of  the  costal  cartilages  is  more  common  in 
men  than  in  women. 

The  elasticity  of  the  thoracic  cage  serves  several  useful 
ends  : 

1.  It  enables  the  component  parts  of  the  cage  to  be  so  bent 
during  the  respiratory  movements  as  to  increase  or  diminish 
thoracic  capacity.  One  is  apt  to  think  that  the  sternum, 
ribs,  and  cartilages  always  preserve  the  same  form,  and 
that  they  have  exactly  the  same  curvatures  at  the  end  of  a 
deep  inspiration  or  expiration  as  in  the  mean  position  of 
the  thorax ;  but  such  is  far  from  being  the  case.  During  a 
deep  inspiration  the  anterior  vertical  convexity  of  the 
sternum  increases,  the  upper  costo-cartilages  tend  to  bulge 
forwards  beyond  the  sternum,  while  the  ribs  themselves 
undergo  considerable  bending.  For  the  most  part  they 
straighten  out,  the  posterior  bends,  or  '  angles,'  however, 
becoming  more  pronounced,  as  may  be  felt  by  placing  the 
hand  upon  them  during  a  deep  inspiration.  These  various 
structures  are  also  bent  during  a  deep  expiration,  but  in  a 
contrary  manner.  The  former  we  may  term  the  '  in- 
spiratory,' and  the  latter  the  '  expiratory,'  bend. 

The  mean  or  neutral  position  of  the  thoracic  cage — 
i.e.,   that   position    in    which    its    constituent    parts    are 


THE    ELASTICITY    OF   THE   THORACIC    CAGE         21 

wholly  unbent — does  not,  as  one  is  so  apt  to  suppose, 
correspond  to  that  attained  at  the  end  of  an  ordinary 
expiration,  for  then  the  thoracic  cage  is  bent  somewhat 
inwards  by  pulmonary  suction.  It  more  nearly  corresponds 
to  the  position  which  the  chest  assumes  at  the  end  of  an 
ordinary  inspiration.  The  fact  is  that  ordinary  expiration 
starts  at  about  the  neutral  position,  the  lungs  during  the 
entire  period  of  expiration  sucking  in  the  thoracic  cage 
beyond  that  position.  This  is  shown  by  the  fact  that 
when  the  chest  is  opened  after  death,  and  pulmonary 
suction  thus  arrested,  the  thoracic  cage  expands. 

The  inspiratory  and  expiratory  bends  induce  recoils 
which  become  factors  in  producing  the  respiratory  move- 
ments. Thus,  at  the  end  of  an  extraordinary  inspiration 
the  cage  recoils  by  virtue  of  the  inspiratory  bend  towards 
the  neutral  point,  being  helped  in  this  movement  by  pul- 
monary suction ;  and,  similarly,  at  the  end  of  an  extra- 
ordinary expiration  an  outward  recoil  occurs  by  virtue  of 
the  expiratory  bend,  this  movement  being,  of  course, 
assisted  by  the  action  of  the  costal  elevators. 

The  part  played  by  thoracic  recoil  in  ordinary,  tranquil 
breathing  requires  special  reference.  We  have  seen  that 
at  the  commencement  of  an  ordinary  expiration  the  chest 
is  in  the  neutral  position,  or  nearly  so,  and  that  it  becomes 
bent  inwards  during  the  expiration ;  consequently,  at  the 
end  of  it  an  outward  recoil  is  available  as  an  inspiratory 
force,  and  carries  the  cage  back  towards  the  neutral  position, 
which,  according  to  Douglas-Powell,  is  barely  reached  in 
ordinary  inspiration.  Inasmuch,  therefore,  as  the  move- 
ment of  the  ribs  during  ordinary  inspiration  is  purely  a 
matter  of  recoil,  '  the  sole  resistance  to  be  overcome  by  the 
inspiratory  muscles  is  that  of  the  lungs.'* 

*  Douglas-Powell  arrives  at  the  above  conclusion  in  the  following 
way.     After  death,  when  the  chest  is  in  a  position  of  ordinary  expira- 


22  RESPIRATORY   EXERCISES 

What  happens,  then,  is  this :  During  expiration  the  ribs, 
cartilages,  and  sternum  are  bent  into  a  position  from  which 
they  tend  to  recoil  outwards,  and  during  inspiration  the 
insph-atory  muscles  exert  just  sufficient  force  to  overcome 
pulmonary  suction,  the  thoracic  cage  by  its  passive  recoil 
assuming  the  position  attained  at  the  end  of  ordinary 
inspu'ation,  and  not  offering  any  dead  weight  to  be  raised 
by  the  inspiratory  muscles.  It,  however,  appears  to  me  an 
error  to  suppose,  as  Douglas-Powell  apparently  does,  that 
inspiration  is  facilitated  by  this  arrangement. '■= 

2.  The  elasticity  of  the  thoracic  cage  enables  its  com- 
ponent parts  to  move  more  or  less  independently  of  one 
another.  Consider  what  would  happen  if  the  ribs,  carti- 
lages, and  sternum  were  absolutely  rigid.  It  would  then 
he  impossible,  unless  we  assume  a  preternatural  laxity  of 
the  joints,  to  move  one  rib  without  moving  all  the  others  to 
the  same  degree.  As  a  matter  of  fact,  however,  during  a 
deep  inspiration,  the  upper  ribs  approximate  to  one  another, 
while  the  intervals  between  the  lower  ribs  increase.  Andral 
long  ago  pointed  out  that  the  ribs  can  move  independently 
of  one  another,!  and  Sibson  refers  to  the  independent 
action  of  each  intercostal  muscle.*     It  is,  moreover,  pos- 

tion,  the  thoracic  cage  is  bent  inwards  beyond  the  neutral  point ;  for 
upon  opening  the  pleurae,  and  thus  removing  pulmonary  suction,  the 
girth  of  the  chest  is  increased  from  1"68  mm.  to  3"9  mm.;  but  the 
thoracic  girth  in  ordinary  inspiration  is  only  increased  by  2  to  3  mm., 
and  hence  he  concludes  that  in  the  ordinary  quiet  inspiration  of  health 
'  the  limit  of  thoracic  recoil  is  barely  reached.'     Oj).  cit.,  pp.  6-19. 

*  Suppose  pulmonary  suction  were  not  sufficiently  powerful  to  draw 
in  the  bony  thorax  during  ordmarj-  expiration,  there  would  be  so  much 
the  less  opposition  to  the  in.spiratorv  muscles.  The  inspiratory  muscles 
have  to  overcome  pulmonary  suction  minus  tlie  force  of  the  outward 
recoil  of  the  thoracic  cage.  If  we  suppose  pulmonary  suction  to 
diminish  by  this  amount  of  force,  so  that  the  ribs  are  not  drawn  in,  as 
may  happen  in  emphysema,  the  force  to  be  overcome  by  the  inspiratory 
muscles  will  obviously  remain  the  same. 

t  Clin.  Med.,  tom.  i.,  p.  68. 

J  Med.  Chir.  Trans.,  vol.  xxxi.,  p.  3.53. 


THE   ELASTICITY   OF   THE   THORACIC   CAGE         23 

sible — especially  in  women,  whose  upper  ribs  acquire 
unnatural  mobility  from  the  use  of  stays — to  expand  the 
upper  chest  more  than  the  lower,  and  it  is  still  more  easy 
to  do  the  converse  of  this.*  It  is  also  possible,  after  a. 
little  practice,  voluntarily  to  expand  one  side  of  the  chest 
independently  of  the  other,  or  nearly  so.  In  a  patient  who 
had  long  suspected  tubercle  of  the  right  apex,  I  found  the 
movement  on  this  side  greater  than  on  the  other :  by 
constant  attention  to  it,  he  had  got  into  the  habit  of 
expanding  it  more  than  the  other.  Again,  inequality  in 
the  movement  of  the  two  sides  of  the  chest  is  frequently 
observed  in  disease ;  the  whole  of  one  side  may  be  prac- 
tically immobile,  or  the  defective  movement  may  be  limited 
to  two  or  three  ribs. 

3.  Thoracic  elasticity  enables  the  cage  to  adapt  itself 
to  alterations  in  the  volume  of  the  thoracic  contents. 
Thus,  in  phthisis  the  parietes  tend  to  fall  in,  while  in 
pleural  effusion  and  cardiac  enlargement  the  overlying 
walls  tend  to  bulge.  This  adaptation  is  the  more  com- 
plete the  greater  the  elasticity  of  the  cage,  and  it  is 
therefore  more  complete  in  the  young  than  the  old.  It 
serves,  be  it  noted,  a  useful  purpose.  Thus,  if  the  chest- 
wall  did  not  fall  in  in  phthisis,  not  only  would  there  be  a 
considerable  upward  dislocation  of  the  diaphragm,  and  con- 
sequently of  the  heart  and  abdominal  viscera,  but  also 
great  stretching  of  the  bronchi  and  alveoli.  Again,  a 
greatly  enlarged  heart  may  cause  dyspncea,  especially  in 
children,  by  encroaching  on  the  space  which  should  be 
occupied  by  the  lungs,  and  it  is  precisely  in  children  that 
precordial  bulging  is  most  easily  effected.  Such  bulging, 
indeed,  always  accompanies  any  considerable  cardiac  en- 
largement in  their  case,  and  may  be  so  well  defined  and  so 
decided  as  to  render  it  almost  possible  to  map  out  the  shape 

*  See  p.  57. 


24  RESPIRATORY    EXERCISES 

of  the  heart  on  mere  inspection.  It  should  also  be  observed 
that  the  enlarged  heart  often  makes  room  for  itself  by 
thrusting  the  diaphragm  downwards ;  one  can  sometimes, 
indeed,  almost  grasp  the  heart  in  the  epigastrium. 

The  degree  of  thoracic  elasticity  is  important  in  relation 
to  external  compression  of  the  thorax.  A  rigid  chest 
resists  compression ;  an  elastic  one  readily  yields  to  it.  It 
would  not  require  much  compression  of  a  child's  chest  to 
destroy  life  completely,  while  it  would  take  a  good  deal 
of  force  to  produce  the  same  effect  in  a  very  muscular 
middle-aged  man. 

The  effect  of  external  compression  of  the  chest  on  the 
circulation  will  be  considered  later.  Suffice  it  here  to  say 
that  it  impedes  the  output  of  blood  from  the  right  heart, 
damming  it  back  upon  the  great  veins.  Hence,  as  Hill  and 
Barnard  observe,  '  it  is  the  weaker  women  and  children  with 
compressible  chests  that,  are  first  affected  in  panic-stricken 
crowds.  .  .  .   The  stronger  man  with  a  rigid  chest  escapes.'* 

The  elasticity  and  consequent  compressibility  and  resiliency 
of  the  thorax  are  of  practical  interest  in  relation  to  artificial 
respiration.  The  more  elastic  the  chest,  the  better  can 
artificial  respiration  be  carried  on,  and  it  is  partly  to  this 
fact  that  Leonard  Guthrie  attributes  the  better  recovery 
from  chloroform  collapse  of  children  than  adults. t  In 
the  former  case  he  recommends  the  application  of  rhythmic 
pressure  to  the  lower  part  of  the  thorax,  while  in  adults  he 
prefers  Silvester's  method. 

*  Jour.  Phijs.,  vol.  xxi.,  p.  334. 

t  Clin.  Jour.,  March  24,  1897,  p.  336. 


CHAPTEE  IV. 

THE  FACTORS  DETERMINING  THE  MEAN  SIZE  OF 
THE   CHEST. 

What  are  the  factors  determining  the  mean  size  of  the 
chest — i.e.,  its  size  when  midway  between  ordinary  inspira- 
tion and  expiration  ?  We  do  not  answer  the  question  by 
saying  that  the  size  of  the  chest  depends  upon  that  of  the 
lungs,  since  this  statement  gives  no  clue  as  to  the  way  in 
which  the  correlation  is  effected.  We  know,  for  instance, 
that  pulmonary  phthisis  diminishes  the  size  of  the  lungs, 
and  that  the  chest-walls  tend  to  collapse  in  consequence ; 
on  the  other  hand,  we  know  that  exercises  which  develop 
the  lungs  expand  the  chest,  and  we  are  apt  to  assume  that 
the  collapse  in  the  one  case  is  due  to  diminished  pulmonary 
support,  and  the  expansion  in  the  other  to  an  actual 
thrusting  outwards  of  the  chest-walls  from  pulmonary 
hypertrophy.  Seeing,  however,  that  pulmonary  suction 
tends  to  draw  in  the  chest-walls,  this  latter  assumption  is 
manifestly  wrong. 

How,  then,  are  we  to  explain  the  correlation  between 
pulmonary  development  and  chest  capacity?  Given  ribs, 
sternum,  heart,  etc.,  of  certain  size,  thoracic  capacity  will 
depend  upon  two  main  factors :  (a)  The  degree  of  pul- 
monary suction  tending  to  contract  the  chest,  and  (/>)  the 
excess  of  tonic  contraction  of  the  muscles  expanding  the 
thoracic  cage  over  that  of  the  corresponding  contractors. 


26  RESPIRATORY    EXERCISES 

(a)  Pulmonary  suction  is  increased  in  phthisis  during 
ordinary  breathing,  for  destruction  of  pulmonary  tissue 
leads  to  excessive  stretching  of  the  unaffected  parts — i.e.,  to 
an  undue  drag  upon  the  visceral  pleura,  this  being  still 
further  increased  by  the  contraction  of  scar  tissue  within 
the  lungs.  Hence,  the  collapse  of  the  chest -walls  in 
phthisis  does  not  result  from  diminished  support  from 
within,  but  rather  from  increased  pulmonary  suction.*  I 
say  that  pulmonary  suction  is  increased  in  phthisis  in 
ordinary  breathing.  In  health  it  is  greater  during  extra- 
ordinary inspiration  than  it  is  in  phthisis. 

Pulmonary  suction  is,  on  the  other  hand,  diminished  by 
exercises  tending  to  develop  the  lungs,  for  the  more  per- 
fectly the  air-passages  and  alveoli  are  developed — and  it 
must  be  remembered  that  in  ill-developed  lungs  a  number 
of  alveoli  are  partly  or  completely  collapsed — the  less  will 
the  elastic  elements  of  the  lungs  be  stretched,  and  the  less 
will  be  the  traction  upon  the  visceral  pleura.  Hence, 
increased  development  of  the  lungs  expands  the  thorax, 
not  by  thrusting  it  outwards,  as  Lagrange  assumes,!  but 
by  diminishing  the  suction  on  its  inner  walls. 

(h)  Next  as  regards  the  muscle  factor.  First  be  it  noted 
that  the  thoracic  elevators  are  much  more  constant  in  their 
action  than  the  corresponding  depressors,  for  ordinary 
expiration  may  be  regarded  as  purely  passive,  while  even 
in  the  extraordinary  breathing  attending  muscle  exercise 
the  inspiratory  muscles  are  much  more  actively  engaged 
than  the  expiratory.  This  is  because  breathlessness  tends 
to  excite   the  insjnratory  muscles  more  tlian  tlie  exinratory 

*  The  lungs  are  frequently  adherent  to  the  chest-walls  m  phthisis, 
and  in  such  cases  we  may  speak  of  the  adherent  portions  as  actually 
(Iragtjivrf  in  the  thorax,  rather  than  as  sucking  it  in. 

t  Lagrange  rightly  observes  that  muscle  exercise  develops  the  lungs 
and  enlarges  the  thorax  essentially  by  inducing  breathlessness,  but  he 
does  not  explain  how  breathlessness  produces  this  result. 


FACTORS  DETERMINING  THE  MEAN  SIZE  OF  CHEST     27 

(see  p.  93).  The  influence  of  the  thoracic  elevators  thus 
preponderating  over  that  of  the  depressors,  the  tendency  of 
muscle  activity  is  to  increase  thoracic  capacity. 

There  can  be  no  doubt  that  the  breathlessness  attending 
muscle  exercise  leads  to  an  increase  in  the  mean  size  of  the 
chest.  Such  an  increase  occurs  during  running,  rowing, 
and  the  like.  Thus,  during  a  hundred  yards'  sprint  the 
chest  is  always  very  prominent,  the  respiratory  movements 
taking  place  about  a  larger  mean  than  ordinary,  so  that, 
while  inspiration  exceeds  the  average,  expiration  does  not 
reach  its  usual  limit.  This  increased  mean  thoracic 
capacity  during  muscle  activity  has  a  double  advantage, 
for  not  only  is  the  mean  respiratory  area  thereby  increased, 
but  the  resistance  in  the  pulmonary  circuit  is  diminished* 
— a  great  advantage,  seeing  that  the  right  heart  is  so  apt  to 
be  distended  m  violent  muscle  exercise.  Such  exercises  as 
mounting  a  ladder,  running  upstairs,  hill  -  climbing,  and 
diving,  tend,  by  the  dyspnoea  which  they  induce,  to  cause 
great  expansion  of  the  chest.  So  greatly,  indeed,  may  the 
chest  be  expanded  in  this  way  that  the  lungs  may  become 
unduly  stretched,  and  their  elasticity  thus  permanently 
iajured.  Now,  loss  of  pulmonary  elasticity  is  a  potent 
cause  of  emphysema,  and  hence  it  is  that  exercises  of  this 
kind  may  actually  induce  it.t 

Those  who  inhabit  mountainous  regions  and  who  thus 
habitually  breathe  rarefied  air,  have  expanded  chests. 
This  is  because  the  inspiratory  muscles  are  excited  to 
extreme  activity  by  the  breathlessness  which  the  rarefied 
air  is  apt  to  induce. 

We  see  now  how  it  is  that  those  with  strong  muscle  systems 

and  leading  active  lives  have  more  capacious  chests  than 

those   with   weak   muscle  systems  and    leading  sedentary 

lives.     It  is  among  the  latter  that  the  phthinoid  chest  is 

*  See  Chapter  XIII.  f  Sec  Chapter  XXII. 


28  RESPIRATORY    EXERCISES 

most  frequently  found — the  cliest  of  superextraordinary 
expiration,  as  we  may  term  it,  in  which  the  clavicles, 
scapulfe,  and  sternum  are  low,  the  ribs  very  oblique,  the 
sagittal  diameter  small,  the  costal  arch  very  acute,  and 
the  diaphragm  high,  the  heart  being  correspondingly  high 
up  and  superficial.  The  opposite  type  of  chest  is  met  with 
in  subjects  of  strong  muscle  development :  the  clavicles, 
scapulae,  and  sternum  in  them  are  high,  the  ribs  less  oblique, 
while  the  chest  is  deep,  the  costal  angle  well  opened  out, 
and  the  diaphragm  low,  the  heart  being  correspondingly 
low  and  also  deep.  The  typical  large  -  lunged  emphy- 
sematous chest  is  an  exaggeration  of  this,  and  may  be 
termed  tlie  chest  of  superextraordinary  inspiration. 

How  large  a  share  the  muscles  take  in  determining  the 
mean  size  of  the  thorax  is  well  shown  by  the  effects  of 
paralysis.  I  have  now  under  my  care  a  boy  suffering  from 
idiopathic  paralysis.  Several  of  the  cervical  muscles  are 
paralyzed,  he  has  no  power  of  flexing  the  neck  or  head,  the 
scaleni  are  practically  absent,  while  the  sterno-mastoids  are 
reduced  to  riband-like  bands.  In  consequence  of  this  the 
sternum  has  descended  a  good  inch,  the  ribs  being  cor- 
respondingly oblique,  and  the  chest  very  flat.  The  clavicles, 
instead  of  being  horizontal,  or  nearly  so,  as  they  should  be, 
slope  markedly  downwards  and  inwards,  their  outer  ends 
being  maintained  in  position  by  the  trapezius,  which  is  not 
paralyzed.  This  marked  downward  and  inward  slope  of 
the  clavicles  is,  I  believe,  frequently  met  with  among  those 
with  feeble  muscle  development  and  phthinoid  chests,  and  is 
a  feature  to  be  sought  for. 

Seeing  that  a  feeble  muscle  system  is  common  among 
those  actually  afflicted  with  phthisis,  we  have  an  additional 
reason  why  the  thorax  should  collapse  in  this  disease. 

All  diseases  which  enfeeble  the  muscle  system  tend  to 
diminish  the  chest  capacity.      Thus,  I  have   little   doubt 


FACTORS  DETERMINING  THE  MEAN  SIZE  OF  CHEST     20 

that  in  the  course  of  a  long  debilitating  disease,  such  as 
typhoid  fever,  the  thorax  undergoes  a  decided  diminution, 
provided,  of  course,  it  be  not  already  fixed  from  age.  The 
same  may  even  happen  if  a  sedentary  existence  succeed  to 
an  active,  outdoor  life.  Conversely,  a  single  long  walk  may 
temporarily  increase  the  chest  capacity  in  one  leading  a 
sedentary  life. 

Not  only  the  breathlessness  of  muscle  exercise,  but  also 
that  induced  bj'  disease,  tends  to  cause  expansion  of  the 
chest,  and  in  the  same  way — namely,  by  exciting  the 
inspiratory  more  than  the  expiratory  muscles.  Indeed,  in 
most  cases  of  dyspnoea  from  disease  the  chest  is  found  to 
be  in  a  state  of  inspiratory  expansion,  this  expansion  not 
only  increasing  the  respiratory  area,  but  facilitating  the 
pulmonary  circulation  which  is  then  so  apt  to  be  impeded. 
It  should  be  observed  that  thoracic  expansion  does  not 
occur  in  the  dyspnoea  resulting  from  considerable  obstruc- 
tion in  the  air-passages,  which,  on  the  contrary,  induces 
collapse — a  condition  likewise  favoured  by  weakness  in  the 
inspiratory  muscles  and  chest  wall,  and  hence  its  fre- 
quency in  the  bronchitis  of  marasmic  and  rickety  children. 
Wilson  Fox  observes  that  the  chest  is  generally  expanded 
in  cardiac  dyspnoea,  and  I  can  bear  out  this  statement. 
We  can  on  similar  lines  explain — partly  at  least  —  the 
expansion  of  the  chest  during  the  asthmatic  paroxysm.* 

The  important  part  taken  by  the  inspiratory  muscles  in 
determinmg  the  mean  size  of  the  chest  is  well  shown  by 
the  expansion  of  the  thoracic  cage  which  takes  place  at 
birth.  I  believe  this  to  be  due  to  tonic  contraction  of 
certain  thoracic  elevators.  Before  birth  the  lungs  are 
collapsed.     Immediately  after  birth  they  expand,  and  the 

*  See  Wilson  Fox,  '  Treatise  on  Diseases  of  the  Lungs,"  pp.  65-67. 


30  RESPIRATORY   EXERCISES 

thorax  is  correspondingly  enlarged ;  this  enlargement  could 
not  be   maintained  except  by  muscle-action.      It   is  true 
that  pulmonary  suction  is  absent  in  the  new-born  animal 
(the  lungs  suffering  no-  collapse  if  the  pleurae  are  opened 
immediately  after   birth),    and   consequently  the   thoracic 
cage  is  subjected  to  the  same  pressure  on  its  inner  as  on 
its  outer  side ;  but  even  with  this  supporting  pressure  from 
within,  the  cage  would  yet  surely  tend  to  shrink  to  its  ante- 
partum dimensions  did  not  the  expansile  forces  of  respiration 
preponderate  over  the  contractile.*    Moreover,  it   is   not 
long  before  pulmonary  suction  is  established,  and  this,  I 
suggest,  is  due  to  the  gradual  increase  in  the  mean  size  of 
the  thoracic  cage,  owing  to  the  preponderating  action  of 
the  costal  elevators,  the  elastic  fibres  of   the  lungs  being 
thereby  put  on  the  stretch,  rather  than  (as  has  been  sug- 
gested) to  the  thoracic  cage  growing  more  rapidly  than  the 
lungs,  though  such  inequality  in  rate  of  growth  may  con- 
tribute to  the  result. 

We  have  not  yet  explained  why  the  mean  size  of  the 
chest  should  be  jJermanently  increased  as  the  result  of  long- 
continued  overaction  of  the  inspiratory  muscles,  and  why  it 
does  not  shrink  to  its  pristine  dimensions  directly  excessive 
inspiratory  action  ceases.  Suppose  that,  by  means  of  suitable 
exercises,  we  increase  the  mean  thoracic  girth  from  32  to 
36  inches  ;  this  signifies  that  the  clavicles,  ribs,  and  sternum 
are  held  in  a  new  mean  position,  that  there  has  been  estab- 
lished a  new  mean  position  about  which  the  respiratory 
movements   take   place.     It    may,   indeed,   be   no   longer 

*  Among  the  expansile  forces  of  respiration  we  must,  of  course, 
include  the  action  of  the  diaphragm.  This  is  the  chief  respiratory 
muscle  in  the  infant,  and  it  might  be  argued  that  the  increase  in  mean 
thoracic  capacity  brought  about  at  birth  is  not  due  to  an  increase  in 
the  capacity  of  the  cage,  but  to  a  lowering  in  the  mean  level  of  the 
diaphragm  from  tonic  contraction  of  its  muscle  fibres.  I  imagine, 
however,  that  there  can  be  little  doubt  that  the  capacity  of  the  thoracic 
cage  is  actually  increased  at  birtli. 


FACTORS  DETERMfNING  THE  MEAN  SIZE  OF  CHEST     31 

possible  for  an  individual  whose  chest  has  been  thus 
increased  to  make  it,  by  the  most  forcible  expiration,  as 
small  as  before  the  exercises  were  undertaken.* 

How  is  the  chest  fixed  in  this  new  position,  and  why  does 
it  not  return  to  its  original  size  when  excessive  inspiratory 
action  ceases  ?  This  question  has  never,  so  far  as  I  know, 
been  discussed.  There  are  at  least  two  factors  tending 
to  fix  in  a  new  position  a  chest  which  has  been  chronically 
expanded  : 

(a)  Permanent  shortening,  or  contracture,  of  the  thoracic 
elevators.  Long-continued  overaction  of  these  muscles 
increases  their  tone,  namely,  their  permanent  contraction. 
They  remain  chronically  contracted,  no  longer  relaxing  to 
the  same  extent  as  before  the  period  of  their  overaction. 
This,  in  course  of  time,  leads  to  their  organic  shorten- 
ing, or  contracture,  for  there  can  be  no  doubt  that  long- 
continued  overaction  of  a  group  of  muscles  does  lead  to 
such  shortening.  Thus,  it  is  owing  to  the  preponderating 
action  of  the  great  flexors  of  the  trunk  that  gymnasts  so 
often  contract  the  stooping  posture,  and  the  habitual  flexion 
of  the  forearm  observed  among  horse-riders  may  be  ex- 
plained on  the  same  principle.  A  still  more  remarkable 
illustration  is  afltbrded  by  the  extreme  shortening  that 
takes  place  in  muscles  whose  antagonizers  have  become 
paralyzed.  It  is  to  a  similar  shortening  of  the  thoracic 
elevators  that  the  permanent  expansion  of  the  chest  above 
referred  to  is  largely  attributable. 

(l))  Alteration  in  the  joints,  their  articular  surfaces  and 
ligaments  undergoing  changes  adapting  them  to  their  new 
position.  In  later  life  a  veritable  ankylosis  of  them  may 
occur. 

*  I  am  referring  to  ordinary  cases.  In  instances  it  might  be  possible 
for  the  individual  whose  chest  liad  been  considerably  expanded  by 
exercises  to  reach  his  original  expiratory  limit.  This,  however,  would 
necessitate  gi-eat  thoracic  mobility,  and  would  probably  only  be  possible 
if  special  exercises  for  mcreasing  expiratory  mobility  were  resorted  to. 


CHAPTEK  V. 

THE  MOBILITY  OF  THE  THORACIC  CAGE. 

The  mobility  of  the  thoracic  cage  is  determined  by  many 
circumstances,  such  as  the  expansibility  of  the  lungs  and 
the  condition  of  the  abdominal  viscera.  There  is,  however 
what  may  be  termed  an  intrinsic  mobility  of  the  thoracic 
cage,  due  to  its  elasticity  and  the  mobility  of  its  various 
joints,  independent  of  conditions  within  and  without  the 
chest,  and  capable  of  being  accurately  tested  in  the  freshly- 
prepared  '  ligamentous  thorax.' 

Among  the  factors  determining  thoracic  mobility,  special 
reference  must  be  made  to  the  action  of  certain  thoracic 
muscles.  Thus,  depression  of  the  ribs  may  be  limited  by 
permanent  shortening  of  the  costal  elevators. 

Individuals  differ  very  considerably  in  respect  of  thoracic 
mobility.  The  most  mobile  chests  are  met  with  in  the 
young,  for  in  them  the  bones  and  cartilages  are  very 
flexible  and  the  thoracic  joints  freely  movable.  With 
advancing  years  the  thoracic  cage  gets  less  and  less  mobile, 
until  in  old  age  it  may  become  almost  completely  fixed. 
This  is  due  to  increasing  rigidity  of  the  bones  and  cartilages, 
to  stiffness  and  even  ankylosis  of  the  thoracic  joints,  and 
generally  also,  I  believe,  to  contracture  of  the  thoracic 
elevators. 

We  must  not  neglect  to  reckon  among  the  thoracic  joints 
the  articulations   between   the   costal   cartilages   and   the 


THE    MOBILITY   OF   THE    THORACIC    CAGE  33 

sternum.  These  joints  are  provided  with  synovial  mem- 
branes and  admit  of  considerable  movement.  In  old  age, 
however,  they  tend  to  disappear,  the  cartilages  undergoing 
calcification  and  becoming  welded  with  the  sternum,  with 
which  they  then  form  one  rigid  piece.  In  like  manner  the 
costo- vertebral  joints  tend  to  stiffen  with  age,  owing, 
apparently,  to  shortening  and  thickening  of  the  ligaments, 
and  to  the  deposition  of  new  bone  in  the  neighbourhood  of 
the  joints. 

Thoracic  mobility,  as  John  Hutchinson's  classical  obser- 
vations show,  tends  to  increase  with  stature,  and  it  is  owing 
to  this  circumstance  rather  than  to  increase  in  mean  thoracic 
capacity  that  '  vital  capacity '  tends  to  increase  with  it 
also. 

Arnold*  confirms  Hutchinson's  observation  as  to  the 
relation  between  stature  and  thoracic  mobility.  He  finds 
the  average  thoracic  mobility  for  various  heights  to  be 
as  follows  : 

Height.  Chest  mobUity. 

157  to  165  cm 6-5  cm. 


165  „  170 
171  „  175 
177  „  180 
181  „  191 


7 

7-5 
8 
8-5 


Arnold  also  finds  that  the  mobility  of  the  chest  tends  to 
increase,  though  not  to  the  same  extent,  with  its  girthf 
as  well  as  with  the  height  of  the  individual.  This  is  not 
surprising,  seeing  that  the  height  and  girth  of  the  thorax 
tend  to  increase  together. 

While  the  most  rigid  chests  are  most  frequently  met 
with  in  the  aged,  rigid  chests,  as  Frederick  Eoberts  observes, 
are  not  uncommon  in  young  subjects,  in  whom  they  are  often 

*  "Waklenburg,   '  Die  Pneumatische  Beliandlung  der   Eespirations- 
und  Circulations-kranldieiten.'     Berlm,  1880,  s.  161. 
t  Ibid.,  s.  115. 

3 


34  RESJPIHATORY    EXERCISES 

traceable  to  '  hard,  physical  work,  and  excessive  indulgence 
in  athletics  and  allied  exercises.'*  I  believe  that  the  breath- 
lessness  induced  by  excessive  muscle  exercise  is  largely 
responsible  for  the  fixity  of  the  chest  in  these  cases,  leading 
as  it  does  to  overaction  and  contracture  of  the  thoracic 
elevators,  and  not  infrequently  to  actual  emphysema  also.f 

Another  cause  of  thoracic  rigidity  in  muscular  subjects 
has  been  suggested  to  me  by  Dr.  McCann.  It  is  that 
powerful  thoracic  muscles  imply  correspondingly  strong 
ribs  and  sternum.  We  know  that  the  skeleton  is  more  mas- 
sive and  that  the  roughened  osseous  surfaces  for  the  attach- 
ment of  muscles  are  more  pronounced  in  those  of  powerful 
muscle  development  than  in  those  with  feeble  muscle 
systems,  and  we  can  scarcely  doubt  that  this  implies  a 
corresponding  rigidity  of  the  bones. 

Hence  laborious  muscle  exercise  must  be  included  among 
the  causes  of  thoracic  immobility.  All  diseases  which 
induce  breathlessness  tend  in  like  manner  to  limit  the 
mobility  of  the  chest,  and  in  consequence  we  never  find 
a  freely  mobile  chest  in  those  suffering  from  emphysema,  + 
chronic  bronchitis,  and  serious  heart  disease. 

Another  cause  is  the  inactivity  of  the  muscle  system 
with  its  consequent  restriction  of  respiratory  movement. 
It  is  indeed  astonishing  how  immobile  the  chest  generally 
is  in  those  leading  sedentary  lives.  This  is  especially 
noticeable  among  women,  many  of  whom  seldom,  if  ever, 
resort  to  deep  breaths.  The  breathing  being  thus  habitually 
shallow,  the  respiratory  range  graduall}^  narrows. 

Defective  moljility  does  not  always  involve  the  entire  cage 
equally.  Thus,  in  the  civilized  woman  the  lower  part  may, 
owing  to  the  use  of  stays,  be  comparatively  fixed,  while  the 

*  Dr.  Iloberts  does  not  explain  how  the  rigidity  is  broujjht  about. 
t  See  Chapter  XXII. 

%  The  way  in  which  emphysema  induces  fixity  of  the  chest  is  con- 
sidered in  detail  in  Chapter  XXII. 


THE   MOBILITY    OF   THE    THORACIC   CAGE  35 

upper  part  may  be  abnormally  mobile.  In  the  man,  on 
the  contrary,  the  defective  movement  may  be  most  notice- 
able in  the  upper  part. 

Means  of  testing  Thoracic  Mobility. — Thoracic  mobility 
may  be  estimated  in  various  ways.  The  most  accurate 
method  is  to  ascertain  the  relation  between  '  vital  capacity  ' 
and  the  mean  size  of  the  thorax.  The  greater  the  former 
in  relation  to  the  latter,  the  greater  the  mobility.  There  is 
no  convenient  way  of  exactly  determining  mean  thoracic 
capacity,  but  for  all  practical  purposes  it  may  be  arrived 
at  by  adding  the  girth  and  height  (measured  in  the  nipple 
line)  of  the  thorax.  In  this  way  we  obtain  a  figure  which 
bears  a  fairly  constant  ratio  to  capacity.* 

Another  plan  is  to  take  the  difference  between  thoracic 
girth  at  the  end  of  a  complete  mspiration  and  expiration. 
The  measurement  should  be  made  both  at  the  level  of  the 
nipples  and  of  the  xyphoid  cartilage,  seeing  that  mobility 
is  sometimes  greater  at  the  one  end  and  sometimes  at  the 
other.  The  average  difference  between  maximum  and 
minimum  in  the  male  adult  is,  in  my  experience,  about 
2  inches.  Fetzer  found  it  to  range  among  392  recruits 
between  4  and  12  cm.,  the  range  being  most  generally 
between  6  and  10  cm.  I  have  known  a  man  to  claim  a 
difference  of  6  mches,  but  this  must  be  very  exceptional. 
At  Barnum's  Show  in  London  a  few  years  back  was  a  man 
possessed  of  extraordmary  chest  mobility.  By  forcibly 
expanding  his  thorax  he  was  able  to  snap  a  strong  belt 
fastened  round  the  chest  when  in  the  position  of  full  expira- 
tion. It  should  be  mentioned  that  those  endowed  with 
large  and  powerful  thoracic  muscles  can  effect  a  consider- 
able increase  in  thoracic  girth  simply  by  contracting  these 

*  In  the  case  of  the  very  stout  it  may  be  necessary  to  take  oti' 
some  inches  from  thoracic  gu-th  in  order  to  arrive  at  the  right 
measurement. 

3—2 


36  RESPLRATORY    EXERCISES 

muscles,  and  thus  causing  them  to  swell  up.  Sandow,  for 
mstance,  claims  to  be  able  to  increase  his  chest  circum- 
ference from  48  to  62  inches — i.e.,  to  the  extent  of  14  inches. 
I  have  little  doubt  that  this  increase  is  brought  about  almost 
entirely  by  the  swelling  up  of  the  great  muscles  enveloping 
the  chest.  It  is  probable  that  the  increase  in  his  bony 
chest  is  not  more  than  from  2  to  3  inches,  seeing  that  his 
vital  capacity  is  only  275  cubic  inches. 

Thoracic  mobility  can  further  be  tested  by  noticing  the 
degree  to  which  the  costal  arch  opens  up  and  closes  during 
an  extreme  inspiration  and  expiration ;  also  by  observing 
the  extent  to  which  the  episternal  notch  can  be  raised  and 
depressed.  In  a  very  mobile  chest  it  can  be  made  almost 
to  touch  the  chin  when  the  head  is  held  erect.  This  latter 
test  is,  however,  somewhat  unreliable,  seeing  that  in  some 
cases  the  chest  may  be  lifted  in  mass  without  undergoing 
appreciable  expansion. 

By  means  of  respiratory  exercises  the  mobility  of  the 
chest  may  be  very  considerably  augmented,  these  exercises 
leading  to  development  of  the  lungs  and  respiratory  muscles 
and  to  increased  flexibility  of  the  ribs  and  sternum,  as  well 
as  to  a  loosening  of  the  thoracic  joints  when  these  have 
become  stiff.  The  j^ounger  the  subject,  the  greater  is  the 
gain  in  mobility  likely  to  be.  If  he  be  under  twenty-five 
years  of  age,  he  may  be  able  to  increase  a  maximum- 
minimum  difference  of  1^  inches  to  3,  4,  or  even  more 
inches,  and  even  after  middle  life  we  may  effect  a  consider- 
able augmentation.  Not  only  are  we  thus  able  to  increase 
thoracic  mobility,  but  also  to  delay  the  advent  of  senile 
rigidity.  It  is  not  surprising  that  the  latter  should  set  in 
prematurely  in  those  who  seldom  or  never  resort  to  extra- 
ordinary breathing. 

For  means  of  increasing  thoracic  mobility  the  reader  is 
referred  to  Chapter  XXI. 


CHAPTER  VI. 

THE  PLEURA  AND  THEIR  FUNCTIONS— THE 
MOVEMENTS  OF  THE  LUNGS. 

The  Functions  of  the  Pleurae. — The  pleurse  consist  of  two 
large  lymphatic  sacs  into  which  the  lymph  is  pumped 
from  the  peritoneum  by  the  respiratory  movements  and 
thence  through  the  lungs  and  thoracic  j)arietes.  Their 
chief  function  is  to  enable  the  lungs  to  expand  equally  and 
in  all  directions.  Seeing  that  the  visceral  and  parietal 
surfaces  are  in  apposition,  and  that  the  lungs  in  conse- 
quence remain  in  contact  with  the  chest-wall,  every  expan- 
sion and  contraction  of  the  chest  leading  to  a  corresponding 
expansion  and  contraction  of  the  lungs,  the  question  not 
unnaturally  occurs.  What  need  is  there  for  the  pleurae  ? 
Why  should  not  the  lungs  be  adherent  to  the  chest-wall '? 
The  answer  is  a  simple  one :  It  is  because  such  an  arrange- 
ment would  not  permit  of  their  equal  expansion  in  all 
directions  during  inspiration.  Simple  diaphragmatic 
breathing,  e.g.,  would  cause  the  lowermost  vesicles  only 
to  expand,  and  these  very  unequally,  seeing  that  all  parts 
of  the  diaphragm  do  not  move  to  the  same  extent,  while 
the  upper  portions  of  the  lungs  would  probably  suffer  no 
expansion  whatever.  By  means  of  the  pleura,  however, 
the  lungs  are  enabled  to  move  in  various  directions  within 
the  chest,  and  thus  to  expand  in  all  their  parts,  so  that 
even  in  pure  abdominal  inspiration,  in  which  the  thorax 


38  RESPIRATORY    EXERCISES 

enlarges  iii  the  vertical  diameter  only,  the  upper  parts  of 
the  lungs  are  enabled  to  expand  freel}'. 

It  has  been  urged — among  others  by  Oertel — that  when 
the  diaphragm  descends,  it  is  the  basic  portions  of  the 
lungs  that  are  chiefly  expanded,  and  that  when,  on  the 
other  hand,  the  upper  part  of  the  thorax  is  expanded  more 
than  the  lower,  pulmonary  expansion  takes  place  in  the 
apical  regions  chiefly — in  short,  that  the  lung  expands 
most  when  the  movement  of  the  overlying  chest-wall  is 
most  marked.  Sibson  held  the  same  view,  and  enunciated 
it  in  precise  terms.* 

There  can  be  little  doubt  that  it  is  correct,  though  I 
think  Oertel  and  Sibson  push  it  too  far.  Thus,  during  an 
abdominal  breath  air  appears,  from  the  test  of  auscultation, 
to  enter  the  apices  freel3%  It  is  therefore  questionable 
whether  there  is  anj^  foundation  for  the  view  that  tubercle 
is  prone  to  attack  the  apices,  because  in  ordinary  breathing, 
which  is  mainly  abdominal,  they  expand  much  less  than 
the  bases.  When,  however,  the  pleurae  are  adherent,  the 
case  is  different,  for  whatever  interferes  with  the  upward 
and  downward  gliding  movement  of  the  lungs  within  the 
chest  will  necessarily  interfere  with  the  proper  ex^mnsion 
of  the  apices  in  ordinary  breathing.  Hence,  those  with 
pleuritic  adhesions  should  frequently  resort  to  costal 
breathing. 

The  Lower  Limits  of  the  Pleurae. — It  is  necessary  to 
ascertain  the  lower  limits  of  the  pleurae,  for  these  deter- 
mine those  of   the  lungs   when   expanded  to  their  fullest 

*■  According  to  this  authority,  ascent  of  the  first  five,  or  thoracic 
ribs  expands  the  superior  and  middle  lobes  ;  elevation  of  the  sixth  to 
eighth,  or  intermediate  ribs,  expands  '  the  upper  portion  of  the  lower 
lobe,  and  on  descent  of  it,  the  lower  portion  of  the  upper  lobe ';  while 
elevation  of  the  ninth  to  twelfth,  or  diaphragmatic  ribs,  expands  the 
lower  and  back  part  of  the  lungs. — Med.  Chir.  Trans.,  vol.  xxxi., 
pp.  357-359. 


THE    PLEURAE    AND    THEIR    FUNCTiONS  39 

possible  extent.  Each  pleura  extends  downwards  as  far  as 
the  attachment  of  the  diaphragm  to  the  thorax.  It  is 
stated  by  some  writers  that  the  diaphragm  is  attached  to 
the  rim  of  the  costal  arch,  and  this  gives  the  erroneous 
impression  that  the  lungs  may  extend  as  far  as  this.  Such 
is,  however,  not  the  case.  Posteriorly,  the  diaphragm  is. 
attached  to  the  bodies  of  the  lumbar  vertebra3,  to  the  tip 
of  the  transverse  processes  of  the  tirst  lumbar  vertebrae,, 
and  to  the  twelfth  ribs ;  outside  this  it  is  attached  to  the 
lower  margin  of  the  costal  arch  and  to  the  ihiwr  aspects  of 
the  last  six  ribs,  this  internal  attachment  extending  in  the 
mid-axillary  line  about  1  vertical  inch,  and  in  the  nipple 
line  about  2  inches,  beyond  the  arch,  while  inside  this  line 
it  gets  progressively  smaller.  Thus,  the  upper  limit  of  the 
diaphragmatic  attachment,  and  consequently  the  lower 
limit  of  the  pleura,  does  not  correspond  with  the  costal 
arch,  the  margin  of  which  the  lungs  can  therefore  never  be 
made  to  reach. 

The  Movements  of  the  Lungs  within  the  Chest. — During 
ordinary  breathing  the  lungs  move  forwards  and  down- 
wards, movement  being  most  marked  below  and  in  front — 
i.e.,  where  the  thorax  is  most  movable.  Hence,  pleuritic 
adhesions  cause  a  greater  interference  with  the  movement 
of  the  lungs  in  this  situation  than  elsewhere.  In  the 
posterior  and  apical  regions  they  interfere  very  little  with 
pulmonary  movement. 

The  way  in  which  the  lungs  move  within  the  thorax 
depends  very  largely  upon  the  way  in  which  the  latter  is 
expanded.  In  the  woman,  in  whom  the  chest  is  more 
movable  above  than  below,  there  may  be — especially  when 
the  stays  are  worn — a  gliding  upwards  of  the  lungs  during 
tranquil  inspiration  ;  in  purely  abdominal  breathing  the 
movement  is  almost  entirely  downwards,  while  in  a  costal 
breath  with  lixed  clavicles  it  is  almost  wholly  forwards.     In 


40  RESPIRATORY   EXERCISES 

a  costal  breath  with  elevation  of  the  clavicles  it  is  upwards 
as  well  as  forwards. 

It  may  here  be  observed  that  it  is  possible  to  move  the 
lungs  within  the  chest  without  actually  breathing.  Thus, 
the  diaphragm  may  be  made  passively  to  ascend  and 
descend — the  lungs,  of  course,  following — by  alternately 
raising  and  depressing  the  lower  ribs  with  closed  glottis ; 
and,  similarly,  the  lower  costal  chest  may  be  made  passively 
to  contract  and  expand  by  contracting  with  closed  glottis, 
first  the  diaphragm,  and  then  the  transversales  abdo- 
minalis. 

It  is  useful  to  ascertain  the  limits  within  which  the 
pulmonary  margins  are  capable  of  moving,  for  in  this  way 
we  can  gain  information  as  to  the  presence  of  pleuritic 
adhesions,  and  also  as  to  the  effects  of  treatment. 

Inasmuch  as  the  lower  pulmonary  margins  travel  up  and 
down  with  the  respiratory  movements,  it  is  clear  that  they 
have  no  fixed  boundary,  and  that  they  cannot  correspond 
to  the  lower  limits  of  the  pleurae.  As  a  matter  of  fact,  the 
lungs  only  extend  thus  far  when  the  fullest  possible  inspira- 
tion is  made,  and  then  only  if  well  developed.  The  mean 
position  of  the  lower  pulmonary  margin  differs  somewhat 
on  the  two  sides,  owing  to  the  asymmetrical  position  of  the 
heart.  It  is  roughly  represented  by  a  line  drawn  from  the 
sterno-xyphoid  articulation  sloping  slightly  downwards  to 
the  spine,  and  cutting  the  upper  border  of  the  sixth  rib  in 
the  nipple  line,  the  eighth  rib  in  the  axillary  line,  and  the 
tenth  rib  posteriorly. 

The  extent  to  which  the  lower  margin  of  the  lung  travels 
down  in  ordinary  inspiration  may  be  ascertained  l)y  {a)  in- 
spection and  (/>)  percussion. 

(a)  During  the  movements  of  the  diaphragm  the  liver 
moves  up  and  down,  but  it  does  not  move  bodily,  the 
coronary  ligament  fixing  the  organ  posteriorly,  and  allowing 


THE    PLtURiE    AND    JIIEIR    FUNCTIONS  41 

it  to  swing  iTp  and  down,  as  upon  a  hinge,  so  that  the 
movement  is  greatest  in  front  and  least  behind.  Now,  it 
is  probable  that  the  movement  of  the  anterior  margins 
of  the  liver  and  of  the  lower  pulmonary  margin  in  front 
practically  correspond,  and  we  are  sometimes  able,  by 
careful  inspection  of  the  abdomen,  to  see  the  anterior 
margin  of  the  liver  moving.  I  have  several  times  observed 
this,  both  when  the  liver  has  been  normal  and  when 
enlarged.  The  extent  of  the  movement  is  about  half  an 
inch  in  ordinary,  and  nearly  2  inches  in  extraordinary, 
breathing  ;  and  we  may  accept  these  figures  as  representing 
the  extent  to  which  the  lower  margin  of  the  lung  moves  in 
each  case. 

I  have  been  able  to  ascertain  by  inspection  that  the 
downward  movement  of  the  lung  is  as  great  posteriorly 
as  anteriorly.  A  child,  five  years  of  age,  had  considerable 
collapse  of  the  right  lung  in  consequence  of  empyema, 
the  left  lung  being  compensatorily  hypertrophied,  and  its 
movements  correspondingly  exaggerated.  There  was  ex- 
treme emaciation,  and  this  enabled  me  to  observe,  through 
the  thin  chest  wall,  the  ascent  and  descent  of  the  lower 
edge  of  the  hypertrophied  lung. 

(h)  Percussion  in  suitable  subjects  confirms  the  results 
obtained  by  inspection.  The  breath  is  held  at  the  end  of 
an  ordinary  inspiration,  and  the  lower  margin  of  resonance 
then  carefully  percussed  by  means  of  Sanson's  pleximeter. 
When  the  disturbance  in  breathing  due  to  this  cessation  is 
recovered  from,  the  breath  is  again  held  at  the  end  of  an 
ordinary  inspiration,  and  the  line  of  resonance  similarly 
percussed.  In  like  manner  we  can  ascertain  to  what  degree 
the  line  of  resonance  alters  in  extraordinary  breathing. 

In  a  well-developed  man,  with  free  chest  movement,  the 
difference  between  the  uppermost  and  lowermost  limits 
of  the   lower   margin    of  the  lung   in   the   nipple   line    is 


42  HESPLRATORY    EXERCISES 

about  4  inches,  the  lung  in  a  complete  inspiration 
travelling  nearly  as  far  as  the  costal  arch,  and  after  a 
complete  expiration  receding  to  4  inches  or  more  above 
this.  The  lower  margin  of  the  lung,  as  judged  by  per- 
cussion, is  the  same  in  a  full  costal  as  in  a  diaphragmatic 
inspiration,  and  practically  corresponds  to  the  costal  arch — 
i.e.,  resonance  can  be  got  in  each  case  right  down  to  the 
edge  of  the  arch — a  fact  the  more  remarkable  when  it 
is  reflected  that  the  lung  cannot  actually  extend  thus  far. 
There  can  be  no  doubt  that  the  margin  of  the  lung  travels  as 
far  down  in  a  complete  costal  as  m  a  complete  diaphragmatic 
inspiration,  because  the  diai^hragm  flattens  in  the  former 
case,  owing  to  the  elevation  of  the  costal  arch. 

The  line  of  resonance  in  a  complete  diaphragmatic 
expiration  is  rather  lower  than  in  a  complete  costal  expha- 
tion,  as  one  would  expect. 

The  movements  of  the  anterior  margins  of  the  lung  can 
also  be  ascertained  by  percussion.  In  well-developed  lungs 
the  superficial  area  of  cardiac  dulness  can  be  obliterated 
by  a  deep  inspiration. 


CHAPTEE  VII. 
INSPIRATORY  AND  EXPIRATORY  FORCE. '^ 

The  force  with  which  the  air  is  inspired  and  expired  we 
term  respectively  inspiratory  and  expiratory  force.  It  is 
measured  by  means  of  a  graduated  U-shaped  glass  tube, 
partly  filled  with  mercury,  to  one  end  of  which  is  attached 
a  flexible  tube,  which  is  applied  to  the  mouth  or  nose.  An 
inspiration  or  expiration  is  then  made,  and  the  alteration  in 
the  height  of  the  mercury  read  off. 

"When  the  operation  is  done  _2Jc>-  oram,  a  mouthpiece  is 
fitted  on  to  the  free  end  of  the  tube,  and  introduced  well 
back  on  to  the  base  of  the  tongue.  Care  must  be  taken  that 
the  buccal  cavity  is  not  shut  off  from  the  naso-pharyngeal 
during  the  operation,  for  if  this  should  happen  the  mercury 
may,  on  the  one  hand,  be  sucked  up,  instead  of  breathed 
up  by  the  inspiratory  forces  ;  while,  on  the  other  hand,  it 
may  be  driven  down  by  the  contraction  of  the  buccinators, 
as  in  blowing  a  wind  instrument,  instead  of  being  forced 
down  by  the  expiratory  forces. 

This  difficulty  is  obviated  when  the  operation  is  performed 

*  Our  earliest  knowledge  of  this  subject  we  owe  to  two  English 
workers — Hales  and  Hutchinson.  "Within  recent  years  it  has  been 
taken  up  on  the  Continent  by  Donders  and  a  number  of  German 
observers.  Foremost  among  these  is  Waldenburg,  to  whose  work, 
'  Die  Pncimiatische  Behandlung  dcr  Respirations-  und  Circulations- 
krankheiten,'  BerUn,  1880,  I  am  mainly  indebted  for  tlie  substance  of 
this  chapter. 


44  ,  RESPIRATORY   EXERCISES 

by  -^ay  of  the  nares.  In  this  case  a  nose-piece  is  attached 
to  the  tubing,  and  inserted  into  one  nostril,  inspiration  and 
expiration  being  made  with  closed  mouth,  and  with  the 
nose  so  held  that  the  entire  current  of  air  is  directed  along 
the  tube.  The  objections  to  this  method  are  its  unpleasant- 
ness and  the  extreme  frequency  of  nasal  obstruction. 

All  the  above  objections  are  avoided  by  the  employment 
of  a  mask,  fitted,  in  air-tight  fashion,  to  the  face,  over  the 
nose  and  mouth,  the  latter  being  kept  wide  open  during  the 
operation,  and  care  being  taken  not  to  pfess  the  mask  too 
tightly  against  the  face,  as  by  modifying  the  air-pressure 
within  it  may  influence  the  height  of  the  mercury. 

Breath-power  may  be  tested  either  by  a  sudden  forced 
breath  or  by  a  slow  gradual  one.  In  the  former  case  the 
influence  of  inertia  causes  the  modifications  in  the  height 
of  the  mercury  to  be  greater  than  in  the  latter ;  but  it  is, 
for  practical  purposes,  the  better  method. 

In  testing  a  subject,  several  observations  should  be  taken, 
and  the  maximum  result  recorded.  Some  instruments  are 
provided  with  a  special  mechanism  for  registering  this. 

In  tranquil  breathing  the  mercury  moves  from  1  to  2  mm. ; 
in  forced  breathing  the  movement  is  very  much  greater. 
Thus,  in  average  adult  men  inspiratory  force  varies  from 
80  to  100  mm.  Hg ;  expiratory  force,  from  100  to 
130  mm.  Hg.  In  women  the  former  is  represented  by  from 
60  to  80  mm.  Hg,  the  latter  by  from  70  to  110  mm.  Hg. 

It  will  thus  be  seen,  as  John  Hutchinson  long  ago  pointed 
out,  that  expiratory  force  is  about  one-third  greater  than 
inspiratory.  This  difference  is  not  due  to  a  corresponding 
difference  in  the  strength  of  the  expiratory  and  inspiratory 
muscles,  but  to  the  fact  that  the  former  have  to  overcome 
pulmonary  suction,  the  elasticity  of  the  thoracic  walls,  and 
the  weight  of  the  thorax — all  of  which  aid  the  respiratory 
muscles  in  the  act  of  expiration.  We  thus  see  how  it  comes 
about  that  the  full  expiratory  force  can  only  be  obtained 


INSPIRATORY   AND   EXPIRATORY    FORCE  45 

after  a  full  inspiration,  while  the  full  inspiratory  force  can 
be  obtained  as  well  after  an  ordinary  as  after  an  extra- 
ordinary expiration. 

Breath-force  chiefly  depends  upon  the  strength  of  the 
respiratory  muscles,  the  mobility  of  the  thorax,  and  the 
elasticity  of  the  lungs.  The  important  share  the  last  two 
factors  take  in  the  result  is  shown  by  the  fact  that  in  young 
and  slender  subjects,  with  very  elastic  lungs  and  very  mobile 
chests,  it  has  generally  a  high  relative  value. 

It  should  here  be  observed  that  there  is  no  relation 
between  breath-force  and  vital  capacity ;  the  former  may 
be  great  while  the  latter  is  small,  and  vice  versa. 

The  Breath-Force  in  Disease. — In  emphysema  expiratory 
force  is  always  diminished  in  relation  to  inspiratory.  In 
moderate  degrees  of  this  disease  the  latter  is  normal,  while 
the  former  is  slightly  defective.  When  dyspnoea  begins, 
the  falling  away  of  expiratory  force  is  more  marked,  and 
it  may  actually  become  less  than  the  inspiratory,  continuing 
to  diminish  as  the  disease  advances  till  it  may  even  sink 
to  the  level  of  one -third  of  the  inspirator}^  force.  This 
latter,  for  the  most  part,  continues  at  the  normal,  though  it 
may  rise  above  this,  owing  to  hypertrophy  of  the  inspiratory 
muscles.  In  the  last  stages  of  the  disease  inspiratory  power 
may  sink  below  the  normal,  but  it  always  remains  greater 
than  the  expiratory. 

The  modification  in  breath-force  observed  in  emphysema 
is  doubtless  partly  due  to  loss  of  pulmonary  suction  (which 
works  against  the  inspiratory  and  with  the  expiratory 
movements),  and  partly  to  the  contracture  of  the  inspiratory 
muscles,  and  the  consequent  interference  with  the  expira- 
tory movement. 

In  phthisis,  pleurisy,  and  pneumonia,  inspiratory  power 
is  diminished.  Expiratory  power  is  also  diminished,  but 
remains  greater  than  the  inspiratory,  though  in  some  cases 
of  pleural  effusion  it  may  sink  below  it. 


46  RESPIRATORY    EXERCISES 

In  bronchitis  there  is  deficient  expiratory  force,  as  in  the 
first  stage  of  emphysema.  This  deficiency  is  observed  both 
in  the  acute  and  chronic  forms,  in  the  latter  case  even  when 
micompHcated  by  emphysema. 

In  spasmodic  asthma  there  is  similar  expiratory  de- 
ficiency, and  this  though  pulmonary  elasticity  may  not 
have  suffered. 

Obstruction  in  the  larynx  and  trachea  diminishes  in- 
spiratory force  chiefly  or  solely. 

In  scoliosis  and  kyphosis  inspiratory  and  expiratory  force 
are  both  defective,  but  especially  the  former. 

Fever  leads  to  a  deficiency  in  both,  but  chiefly  in  the 
expiratory  force,  these  changes  being  due  to  the  defective 
muscle-power  and  pulmonary  elasticity  induced  by  the 
febrile  state. 

Relative  Strength  of  the  Inspiratory  and  Expiratory  Muscles, 
— We  have  seen  that  inspiratory  and  expiratory  force  do 
not  respectively  represent  the  strength  of  the  inspiratory 
and  expiratory  muscles.  It  has  even  been  contended  that 
the  inspiratory  muscles  are  the  stronger,  though  I  am  not 
aware  that  this  is  capable  of  proof.  They  are  the  more 
constantly  in  action,  and,  from  the  respiratory  point  of 
view,  the  more  important,  seeing  that  expiration  can  take 
place  without  muscle  action,  while  inspiration  is  wholly 
dependent  upon  it ;  even  in  the  extraordinary  breathing 
induced  by  breathlessness,  the  action  of  the  inspiratory 
muscles  vastly  preponderates  over  that  of  the  expiratory. 
In  spite  of  this,  the  expiratory  muscles,  which  chiefly 
consist  of  the  great  abdominal  muscles,  are  very  powerful. 
Their  great  strength,  however,  is  not  primarily  for  the 
purpose  of  extraordinary  expiration,  but  has  quite  other 
ends,  such  as  fixing  the  chest,  rendering  the  skeleton 
rigid  during  effort,  and  increasing  intra-abdominal  tension 
during  defalcation,  etc.,  in  all  of  which  actions  the  glottis  is 


INSPIRATORY    AND    EXPIRATORY    FORCE  47 

closed  and  expiration  prevented.  It  should  further  be 
observed,  in  this  connection,  that  when  extraordinary 
breathing  is  resorted  to  for  physiological  purposes,  the 
abdominal  muscles  are  never  called  into  full  play.  Seldom, 
if  ever,  does  the  individual  need  to  expire  beyond  the  limit 
of  ordinary  expiration  ;  in  great  breathlessness  he  does  not 
even  expire  thus  far,  the  increased  range  of  respiratory 
movement  which  then  occurs  being  due  to  increased  depth 
of  inspiration. 

It  is  very  seldom,  in  fact,  that  the  '  complemental '  air  is 
got  rid  of,  and  that  the  great  abdominal  muscles  are 
called  upon  to  contract  the  chest  to  the  utmost.  There 
can  therefore  be  no  doubt  that  the  amount  of  muscle-force 
spent  in  effecting  the  inspiratory  movements,  not  only  of 
tranquil  but  also  of  extraordinary  breathing,*  is  vastly  in 
excess  of  that  employed  in  effecting  the  expiratory  move- 
ments, and  that  if  the  expiratory  muscles  are  more  powerful 
than  the  inspiratory,  it  is  because  these  muscles  need 
great  strength  for  other  purposes  than  expiration. 

Special  mention  may  here  be  made  of  the  strength  of 
the  diaphragm.  This  is  a  very  powerful  muscle.  I  am 
acquainted  with  a  man  who  can  actually  move  a  grand 
piano  by  means  of  it,  and  I  have  often  been  struck  with  the 
extraordinary  strength  it  displays  in  disease.  Even  in  the 
last  moments  of  life,  when  the  belly  has  been  tightly 
distended  with  fat  and  ascitic  fluid,  I  have  observed — and 
that  in  an  old  woman — considerable  al)dominal  movement, 
testifying  to  the  strength  of  this  muscle. 

Exercises  for  strengthening  the  respiratory  muscles  are 
given  in  Chapter  XX. 

*  I  refer  here  to  the  extraordinary  breathing  required  for  the 
ordinary  physiological  purposes  of  life.  Wlien  an  individual  volun- 
tarily expu-es  to  the  utmost,  as  in  blowing  into  the  spirometer,  the 
expiratory  muscles  are  brought  into  considerable  play ;  but  such  an 
expiration  is,  so  to  speak,  ultra-physiological. 


CHAPTEE  VIII. 

THE  RESPIRATORY  FORCES. 

While  inspiration  is  essentially  active,  expiration,  unless 
forced,  is  almost  entirely  passive,  the  only  muscles  taking 
part  in  it  being  the  internal  intercostals,  triangularis  sterni, 
and  possibly  also  in  very  slight  measure  the  abdominal 
muscles.  The  passive  forces  of  tranquil  expiration  are  the 
suction  of  the  lungs  on  the  ribs  and  diaphragm,  and  the 
positive  intra-abdominal  pressure  which  tends  to  force 
the  diaphragm  upwards  directly  the  latter  ceases  to  con- 
tract. In  the  upright  position  gravity  also  comes  into  play 
as  an  expiratory  force  by  pulling  the  ribs  down.  These 
passive  expiratory  forces  are,  of  course,  greatest  after  an 
extraordinary  inspiration,  for  the  elastic  recoil  of  the  lungs 
is  then  increased,  and,  moreover,  is  supplemented  by  that 
of  the  thoracic  cage,  and  in  the  vertical  position  of  the 
trunk  the  influence  of  gravity  also — especially  if  the 
shoulders  and  chest  are  bulky — is  considerably  augmented. 
In  the  fullest  possiljle  inspiration,  however,  one  of  the 
passive  expiratory  forces — i.e.,  the  positive  intra-abdominal 
pressure — is  diminished. 

In  forced  expiration  the  expiratory  recoil  is  helped  by  the 
contraction  of  special  expiratory  muscles — the  abdominal 
muscles,  quadratus  lumborum,  serratus  posticus  inferior, 
erectores  spinse,  and  others. 


THE    RESPIRATORY    FORCES  49 

Passive  recoil  plays  very  little  part  in  inspiration.  In 
tranquil  inspiration  the  ribs,  which  during  expiration  have 
been  bent  inwards  beyond  the  neutral  point,  recoil  out- 
wards, and  after  an  extraordinary  expiration  this  outward 
recoil  is,  of  course,  much  increased. 

Inspiration  being  essentially  active,  we  have  next  to 
inquire.  What  are  the  muscles  engaged  in  the  act '?  They 
are :    (1)  those  which  raise  the  ribs,  and  (2)  the  diaphragm. 

1.  In  ordinary  inspiration  the  ribs  are  raised  by  the 
external  intercostals,  the  levatores  costarum,  and  the 
diaphragm.*  The  action  of  the  intercostals  is  assisted  by 
the  comparative  fixity  of  the  first  ribs,  which  are  attached 
by  especially  strong  cartilages  to  the  sternum,  which,  again, 
is  supported  by  the  clavicles.  Hence,  the  first  ribs  afford 
purchase  to  the  intercostal  muscles  below,  and  they  are 
further  fixed  during  inspiration  by  the  contraction  of  the 
scaleni. 

In  extraordinary  inspiration  many  other  costal  elevators 
come  into  play.  These  include  all  those  muscles  which 
directly  raise  the  ribs,  such  as  the  serratus  posticus  superior 
(which  passes  from  the  spine  to  the  second,  fifth,  and  inter- 
vening ribs),  the  cervicalis  ascendens,  and  (when  the  arm 
and  shoulder  are  fixed)  the  serratus  magnus,  the  pectorals, 
and  that  part  of  the  latissimus  dorsi  which  passes  from  the 
humerus  to  the  last  three  ribs,  and  also  those  capable  of 
raising  the  clavicles  and  scapulae,  such  as  the  sterno- 
mastoids,  the  trapezius,  and  the  levatores  anguli.  scapulae. 

The  various  costal  elevators  can  act  independent!}', 
especially  after  practice,  being  thus  able  to  raise  a  limited 
set  of  ribs  more  than,  or  even  quite  independently  of,  the 
others.  Thus,  it  is  possible  to  expand  the  upper  part  of 
the  thoracic  cage  more  than  the  lower,  or  vice  versa,  and  tp 
raise  the  ribs  on  one  side  more  than  on  the  other.f 
*  See  p.  51.  t  See  p.  58. 


50  RESPIRATORY    EXERCISES 

2.  The  diaphragm  arises  from  (a)  the  back  of  the 
ensiform  cartilage ;  (h)  the  inner  surface  of  the  lower  six 
costal  cartilages,  and  sometimes  from  part  of  the  corre- 
sponding bony  ribs  ;  (c)  the  internal  and  external  arched 
ligaments,  extending  respectively  from  the  body  of  the 
second  to  the  tip  of  the  transverse  jprocess  of  the  first 
lumbar  vertebra,  and  from  the  latter  to  the  last  rib ; 
(d)  the  bodies  of  the  first  three  lumbar  vertebrae  as 
the  two  fleshy  crura.  From  this  origin  its  fibres  pass  to 
the  central  tendon,  the  most  anterior,  especially  those 
coming  from  the  xyphoid,  being  short  and  nearly  hori- 
zontal, and  thus  by  their  contraction  tending  to  pull  the 
lower  part  of  the  sternum  and  adjacent  cartilages  back- 
wards ;  while  the  remaining  fibres  arch  upwards  to  their 
insertion,  those  arising  lowest  down  from  the  sides  of  the 
chest  having  the  steepest  ascent,  and — in  the  expiratory 
position  of  the  chest — running  for  some  distance  in  close 
proximity  to  the  ribs.  The  arch  of  these  fibres  is  most 
pronounced  when  they  are  lax,  the  diaphragm  being  then 
dome-shaped,  owing  to  its  being  thrust  upwards  by  the 
excess  of  pressure  on  its  under  surface  over  that  upon 
its  upper.  When  they  contract  the  dome  flattens  out,  the 
thorax  being  thereby  enlarged  vertically  ;  at  the  same  time 
the  central  tendon  and  lower  ribs  are  dragged  upon,  the 
former  being  somewhat  depressed  and  the  latter  raised. 

The  central  tendon  is  prevented  from  any  considerable 
descent  by  its  connection  with  the  pericardium,  which  is 
continuous  with  the  cervical  fasciae ;  the  lower  ribs  are, 
moreover,  under  ordinary  circumstances  steadied  during 
diaphragmatic  contraction  by  the  quadratus  lumborum  and 
serratus  posticus  inferior.  When  the  diaphragm  contracts 
under  these  conditions,  the  chief  effect  is  a  straightening  of 
its  arched  fibres— i.e.,  a  flattening  of  the  dome — the  ribs 
being  only  slightly  raised.     I  find  that  the  girth  of  the 


THE    RESPIRATORY    FORCES  51 

lower  chest  is  only  increased  half  an  inch  after  a  full 
diaphragmatic  breath,  while  that  of  the  belly  is  augmented 
by  2  inches.  By  practice  it  is  possible  to  prevent  any 
raising  of  the  ribs  during  diaphragmatic  contraction,  in- 
spiration being  then  purely  abdominal,  a  term  which 
is  not  synonymous  with  diaphrafimatic  as  applied  to 
breathing.  When,  however,  the  diaphragm  is  firmly  sup- 
ported on  its  under  surface,  as  happens  when  the  abdomen 
is  voluntarily  retracted  or  firmly  compressed,  the  chief 
effect  of  its  contraction  is  to  elevate  the  lower  ribs,  and 
thus  to  open  out  the  costal  arch  and  increase  the  girth  of 
the  lower  chest  * 

This  expansion  of  the  lower  bony  chest  is,  however,  not 
solely  due  to  the  upward  drag  of  the  diaphragm  upon  the 
ribs.  Some  descent  of  this  structure  occurs  even  when  it 
is  firmly  supported  from  below,  and  this  tends  to  thrust  the 
abdominal  viscera  downwards  ;  but  their  downward  move- 
ment being  checked  by  the  firm  pressure  upon  them  of  the 
abdommal  walls,  the  lower  ribs  are  bulged  outwards. 

That  the  tendency  of  the  diaphragm  to  elevate  the  lower 
ribs  increases  with  the  resistance  which  the  anterior  abdo- 
minal walls  oppose  to  the  viscera  can  be  shown  by  a  very 
simple  experiment.  Let  the  hands  rest  on  the  side  of  the 
lower  chest,  and  then  take  a  full  diaphragmatic  breath.  It 
will  be  found  that  the  hands  suffer  very  little  movement. 
Now,  keeping  them  in  the  same  position,  stand  facing  a 
wall,  and  while  pressing  the  abdomen  firmly  against  it  take 
a  similar  inspiration  ;  the  lower  chest  will  then  be  found  to 
bulge  very  appreciably  on  either  side.  On  the  other  hand, 
when  the  abdomen  is  opened,  and  the  support  on  the  under 
surface  of  the  diaphragm  thus  greatly  diminished,  it  no 
longer  acts  as  a  costal  elevator. 

*  It  is,  as  we  shaU  see,  to  this  end  that  some  teachers  of  singing 
advise  that  the  belly  should  be  retracted  during  inspiration,  and  that 
others  advocate  the  use  of  an  abdominal  belt  during  singing. 

4—2 


52  RESPIRATORY   EXERCISES 

I  have  said  that  the  central  tendon  is  only  capable  of 
limited  movement  in  respiration.  Its  range  of  movement 
is  a  point  of  some  interest,  because  it  is  evident  that  the 
heart  must  move  with  it.  When  a  deep  thoracic  inspiration 
is  taken,  the  heart  can  quite  plainly  be  felt  beating  in  the 
epigastrium,  and  this  was  thought  by  Sibson  to  prove  an 
actual  downward  movement  of  the  central  tendon  ;  but  the 
epigastric  pulsation  under  these  circumstances  might  very 
well  be  due  to  the  lifting  upwards  of  the  thoracic  cage  over 
the  heart  rather  than  to  an  actual  descent  of  the  heart 
within  the  thorax.  In  order  to  ascertain  whether  the  heart 
descends,  we  should  measure  the  vertical  distance  between 
the  chin  and  the  apex  of  the  heart  before  and  after  a  deep 
thoracic  breath,  and  applying  this  test  I  do  not  get  any 
evidence  that  the  central  tendon  descends. 

It  is  otherwise,  however,  when  a  full  diaphragmatic 
breath  is  taken  icith  fixed  clavicles;  the  central  tendon 
and  the  heart  then  actually  descend,  as  may  be  shown 
by  means  of  Eontgen  rays. 

The  respiratory  centre  is  automatic.  It  consists  of  an  inspiratory 
and  expiratory  portion,  the  former  alone  acting  during  ordinary  breath- 
ing. The  automatic  action  is  remforced  by  impulses  ascending  the 
vagi  from  the  lungs ;  the  expansion  of  the  Imigs  tends  to  inhibit 
through  these  nerves  the  inspiratory  centre,  and  to  excite  the  expnatory 
centre  ;  and,  on  the  other  hand,  the  contraction  of  the  lungs  tends  to 
check  the  action  of  the  expiratory  centre  and  to  incite  the  inspiratory 
centre. 

JMost  of  the  vagal  fibres  passing  to  the  respiratory  centre  act  upon 
its  inspiratory  portion,  and  the  effect  of  the  impulses  ascending  them  is 
to  quicken  breathing ;  these  fibres  are  in  constant  action.  A  smaller 
number,  especially  those  belonging  to  the  superior  laryngeal  nerves, 
act  upon  its  expiratory  portion.  Hence  it  is  that  irritation  of  the 
larynx  causes  violent  expiratory  efforts.  Impulses  ascending  these 
fibres  tend  to  slacken  the  respirations. 

\\'hile  the  respiratory  nerves  ^;«7'  excellence  are  the  respiratory 
portion  of  the  vagi,  numerous  afferent  nerves  are  capable  of  affecting 
the  respiratory  centre.  Witness  the  effect  of  cold  suddenly  applied  to 
the  back. 


THE   llESPIRATORY   FORCES  53 

Not  only  is  this  centre  influenced  through  the  nerves,  but  also  by  the 
plasma  bathing  it.  Apncea  is  due  to  impulses  ascending  the  vagi,  and 
not  to  altered  plasma,  while  dyspna'a  is  essentially  due  to  the  latter. 
1  n  tliis  condition  the  blood  is  deficient  in  O  and  surcharged  with  CO.^, 
but  the  excess  of  the  latter  plays  only  a  small  part,  as  compared 
with  the  deficiency  of  O,  in  causmg  the  peculiar  breathing  of  dyspnoea. 
The  quickened  breathing  induced  by  muscle  exercise  is  due  to  the 
stinmlation  of  the  medullary  centre  by  certain  unknown  substances. 
The  deficiency  in  O  and  the  excess  of  COg  cannot  be  the  sole  causes  of 
tlie  acceleration  in  this  case,  since  such  alterations  in  the  blood  tend  to 
deepen  rather  than  to  hasten  the  respirations,  as  is  shown  in  dyspncea. 


CHAPTEE  IX. 

MODES  IN  WHICH  THE  THORAX  IS  ENLARGED. 

The  thorax  is  enlarged  by  elevation  of  the  ribs  and  descent 
of  the  diaphragm,  the  former  increasing  the  sagittal  and 
lateral  diameters,  and  the  latter  the  vertical  diameter. 

In  ordinary  tranquil  breathing,  there  is  comparatively 
little  rib  movement,  especially  in  the  upper  part  of  the 
thorax,  respiration  being  chiefly  abdominal.  It  is  true  that 
in  the  civilized  woman  the  ribs,  notably  the  upper  ones, 
often  move  freely,  diaphragmatic  action  being  correspond- 
ingly curtailed  ;  but  this  type  of  breathing  is  not  a  natural 
sexual  characteristic  :  it  is  due  to  the  use  of  stays,  which 
interfere  with  the  free  descent  of  the  diaphragm  and  the 
expansion  of  the  lower  bony  cage.  In  consequence  of  this, 
the  cage  in  its  upper  part  becomes  expanded  and  abnormally 
mobile  (hence  the '  heaving  bosom '  of  the  woman),  while,  con- 
trariwise, the  growth  of  the  lower  chest  is  interfered  with,  its 
movements  being  correspondingly  restricted.  It  is  for  this 
reason  that,  after  the  age  of  fourteen,  the  lower  transverse 
diameter  of  the  chest  is  less  in  the  civilized  woman  than  the 
upper,  in  man  the  reverse  being  the  case  (Sibson). 

While  normal  tranquil  breathing  is  chiefly  abdominal, 
the  part  played  by  costal  elevation  must  not  be  neglected. 
The  increase  in  thoracic  girth  thus  affected  is  only 
2  to  3  mm.,*  but  the  importance  of  this  slight  increase  is 

*  Hutchinson  gives  1  to  2  mm. ;  Burdon  Sanderson,  1  to  6  mm.  ; 
Douglas-Powell,  2  to  3  mm. 


MODES    IX    WHICH    THE    THORAX    IS    EXLARGED       55 

shown  by  the  fact  that  when,  as  from  myelitis  just  below 
the  origin  of  the  phrenics,  the  individual  has  to  depend 
upon  pure  diaphragmatic  breathing,  the  respirations  are 
laboured.*  But  that  the  diaphragm  plays  the  more  im- 
portant part  in  tranquil  breathing  is  evident  from  the  great 
difficulty  of  breathing  resulting  from  its  paralysis. 

Costal  breathing  is  more  developed  in  man  than  in  any 
animal.  If,  for  instance,  we  examine  the  thorax  of  an 
anthropoid  ape,  we  find  that  the  sagittal  diameter  is  nearly 
as  long_as  the  transverse,  and  the  same  feature  is  observed 
in  the  human  infant.  It  is  clear  that  the  capacity  of  such 
chests  cannot  be  greatly  increased  by  elevation  of  the  ribs,  but 
as  the  erect  posture  comes  to  be  assumed,  the  chest  flattens  so 
as  to  throw  the  centre  of  gravity  backwards,  and  thus  keep 
it  vertically  above  the  narrow  basis  of  support  aflbrded  by 
the  feet,  and  in  this  way  the  capacity  for  costal  breathing 
is  increased.  Nevertheless,  as  already  observed,  tranquil 
breathing  is  essentially  diaphragmatic.  This  is  even  more 
the  case  in  the  horizontal  position  than  in  the  upright, 
because  the  pressure  of  the  ribs  against  the  surface  of 
support  interferes  with  their  movement.  Even  among 
women  it  will  be  found  that  m  the  horizontal  position, 
when  no  stays  are  worn,  tranquil  breathing  is  chiefly 
diaphragmatic. 

The  mode  in  which  the  thoracic  cage  expands  is  best 
studied  during  an  extraordinary  inspiration.  The  clavicles, 
scapula^  sternum,  and  ribs  are  then  raised  ;  the  anterior 
extremities  of  the  clavicles  and  ribs  move  forwards  and 
upwards,  carrying  with  them  the  sternum,  which  at  the 
same  time  tends  to  become  convex  anteriorly,  or  to  suffer  an 

*  While  writing  this  1  have  such  a  case  under  observation.  The 
breathing  is  purely  diaphragmatic  and  manifestly  laboured,  although 
the  luugs  are  normal.  It  is,  however,  possible  that  this  laboured  action 
depends  upon  paralysis  of  the  muscles  which  steady  the  lower  ribs,  and 
thus  facilitate  the  inspiratory  action  of  the  diaphragm. 


56  '  RESPIRATORY    EXERCISES 

increase  in  its  natural  convexity,  while  the  posterior  costal 
extremities  move  backwards,  carrying  with  them  the  spine. 
This  may  be  easily  demonstrated  by  placing  the  hand  on 
the  middle  of  the  back  while  a  deep  inspiration  is  being 
made.  The  movement  of  the  upper  ribs  is  chiefly  forwards, 
that  of  the  lower  ribs  chiefly  backwards,  and  Sibson  points 
out,  in  connection  with  this  fact,  that  the  bulk  of  the  upper 
part  of  the  lungs  is  in  front,  while  the  bulk  of  the  lower 
part  is  behind.  The  backward  movement  is  most  marked 
at  that  part  of  the  spine  which  articulates  with  the  sixth, 
seventh,  and  eighth  ribs. 

Were  the  spine  as  movable  as  the  sternum,  elevation  of 
the  ribs  would  cause  it  to  travel  as  much  backwards  as  it 
causes  the  sternum  to  move  forwards,  for  the  ribs  passing 
obliquely  from  spine  to  sternum,  any  diminution  in  their 
obliquity  must  increase  the  distance  between  these  two. 
The  sternum  being,  however,  less  fixed  than  the  spine,  tends 
to  move  the  more,  but  as  it  approaches  its  limit,  i.e.,  towards 
the  end  of  inspiration,  it  ofiers  considerable  resistance  to 
further  movement,  and  it  is  then  that  the  backward  move- 
ment of  the  spine  becomes  most  pronounced. 

As  the  ribs  ascend  they  undergo  some  eversion,  and  this 
tends  to  increase  the  lateral  diameter  of  the  chest,  but  the 
increase  in  the  lateral  diameter  is  chiefly  due  to  a  straighten 
ing  out  of  the  costal  curves. 

In  the  posterior  movement  of  the  ribs,  their  angles  move 
backwards  more  than  the  spine,  thus  deepening  the  spaces 
for  the  lungs  on  either  side  of  the  spine.  During  costal 
ascent  the  upj^er  riljs  approach  one  another,  while  the 
distance  between  the  remaining  ribs,  especially  the  last 
three,  increases,  as  can  be  easily  shown  by  placing  the 
fingers  between  them. 

In  some  the  upper  part  of  the  sternum  moves  forwards 
more  than  the  lower  ;  in  others  the  reverse  occurs. 


MODES    IN    WHICH    THE    THORAX    IS    ENLARGED      57 

Sibson  has  shown  that  the  third,  fourth,  and  fifth  costal 
cartilages  move  forwards  somewhat  beyond  the  sternum. 
When,  however,  the  cartilages  are  rigid  and  welded  to  the 
sternum,  the  latter  advances  more  than  the  cartilages.* 

The  movement  of  the  fourth,  fifth,  and  sixth  cartilages, 
and  of  the  sixth  rib  over  the  heart,  is  somewhat  less  than 
on  the  right  side.     This  is  even  true  of  tranquil  breathing. 

It  is  possible  completely  to  dissociate  costal  from  abdominal 
breathing,  for  though  contraction  of  the  diaphragm  tends  to 
raise  the  lower  ribs,  it  is,  as  already  pointed  out,  possible 
to  check  all  costal  movement  during  diaphragmatic  descent. 

Costal  breathing  falls  under  two  heads  :  (a)  That  in  which 
the  clavicles  are  raised,  and  with  them  all  the  ribs.  When 
such  an  inspiration  is  carried  to  its  extreme,  the  ribs  are 
elevated  to  their  utmost,  and  the  chest  cavity  is  increased 
to  its  maximum.  I  shall  speak  of  this  as  the  pancostal 
method,  {h)  That  in  which  the  ribs  are  raised  without 
elevation  of  the  clavicles.  All  the  ribs  may  be  raised  in 
this  method  by  allowing  the  inner  ends  of  the  clavicles  to 
move  forwards,  but  even  then  the  chief  expansion  takes 
place  in  the  lower  part  of  the  chest.  I  shall  therefore 
speak  of  it  as  the  lower  costal  method. 

There  are  thus  three  primitive  types  of  breathing  in 
the  normal  chest  :  pancostal,  lower  costal,  and  abdominal. 
Much  confusion  may  be  avoided  if  we  keep  this  fact  clearly 
in  mind.  The  so-called  clavicular  variety,  about  which  so 
much  has  been  written,  is,  as  far  as  I  can  see,  impossible 
under  normal  conditions.  In  it  the  clavicles  are  raised  and 
the  upper  part  of  the  chest  is  supposed  to  expand  alone,  or 
at  all  events  greatly  in  excess  of  the  lower  part ;  but  this 
appears  to  me  to  be  absolutely  impossible  under  normal 
conditions,  since  the  lower  ribs  must  ascend  with  the  upper, 

*  The  tendency  of  the  upper  costal  cartilages  to  advance  beyond  the 
sternum  is  often  well  shown  in  the  chest  of  hypcrtrophous  emphysema. 


58  RESPIRATORY    EXERCISES 

and  this  implies  expansion  of  the  lower  chest.  "When,  how- 
ever, the  lower  part  of  the  chest  is  tightly  bound  with  a 
rigid  corset,  it  is  necessarily  incapable  of  proper  exj)ansion 
— if,  indeed,  of  any  expansion  at  all — and  under  these 
circumstances  a  costal  inspiration  causes  an  enlargement 
of  the  upper  chest  chiefly  or  only.  This  part  of  the  chest 
undergoes  in  those  who  habitually  tight-lace  a  compensa- 
tory enlargement  and  acquires  increased  mobility,  and  this 
undue  mobility  of  the  upper  chest  is  observed  in  such  even 
after  the  corset  has  been  removed. 

I  do  not  deny  that  it  may  be  possible  by  practice  to  gain 
such  control  over  the  elevators  of  the  upper  ribs  as  to  cause 
them  to  be  raised  more  than  the  lower  during  inspiration, 
and  thus  to  bring  about  a  relatively  larger  expansion  of  the 
upper  than  of  the  lower  chest.  The  Italian  teachers  of 
singing  lay  great  stress  upon  this  expansion  of  the  upper 
chest,  and  advise  the  singer  to  direct  to  it  all  his  attention 
in  breathing.  To  this  end  the  shoulders  are  held  back,  in 
order  that  the  scapulae  may  afford  jJoiAi^s  cVapiyiii  for  the 
serrati  magni,  which  under  these  circumstances  become 
costal  elevators,  and  there  are,  of  course,  other  special 
elevators  of  the  upper  ribs.  It  must,  however,  be  remem- 
bered that  the  lower  ribs  are  compelled  to  follow  the  upper 
ones,  and  this  necessitates  a  considerable  expansion  of  the 
lower  chest,  unless  the  latter  is  compressed. 

This  is  the  proper  place  to  refer  to  the  retraction  of  the 
lielly  which  accompanies  a  deep  costal  inspiration.  Such 
an  inspiration  causes  flattening  of  the  belly,  the  upper  part 
shelving  suddenly  away  from  the  costal  arch.  This  is 
especially  noticeable  in  the  epigastrium,  which  constitutes 
a  pronounced  hollow.  Exactly  the  same  thing  is  observed 
if,  prior  to  the  costal  breath,  the  belly  be  bulged  by  a  deep 
diaphragmatic  inspiration :  as  the  ribs  are  raised, it  gradually 
recedes,  finally  becoming  scaphoid. 


MODES   IN   WHICH   THE   THOKAX    IS    ENLARGED      50 

This  flattening  or  actual  hollowing  out  of  the  belly  is  due  to 
several  causes.  When  the  ribs  are  elevated  to  the  utmost, 
the  lungs  are  unable,  by  their  fullest  expansion,  to  fill  the 
chest,  unless  the  diaphragm  lies  high.  With  every  increase 
in  the  size  of  the  chest  the  suction  of  the  lungs  on  the  sides 
and  base  of  the  thorax  increases.  It  is  insufficient  to  draw 
in  the  ribs,  which  are  held  in  position  by  powerful  costal 
inspirators,  but  the  diaphragm  is  unable  to  resist  it,  and  is 
thus  sucked  upwards.  So  great  is  this  suction  at  the  end 
of  a  complete  costal  inspiration,  that  the  most  strenuous 
effort  at  diaphragmatic  inspiration  is  powerless  to  cause 
any  diaphragmatic  descent ;  and  it  is  this  suction  which 
determines  the  limit  of  costal  inspiration.  Small,  ill-de- 
veloped lungs  are  very  soon  stretched  to  their  utmost,  and 
therefore  only  permit  of  moderate  costal  expansion  ;  but 
large,  well-developed  lungs  (non-emphysematous)  permit 
considerable  costal  elevation  to  occur  before  suction  puts  a 
stop  to  further  expansion. 

The  eftect  of  the  upward  aspiration  of  the  diaphragm  is 
to  mcrease  the  vertical  diameter  of  the  abdominal  cavity  ; 
the  elevation  of  the  costal  arch  acts  in  the  same  direction, 
and,  moreover,  puts  the  abdominal  wall  on  the  stretch,  while 
the  opening  out  of  the  costal  arch  augments  the  transverse 
diameter  of  the  abdomen  above.  The  abdominal  cavity, 
being  thus  increased  in  its  transverse  and  vertical  diameters, 
necessarily  suffers  diminution  in  its  sagittal  diameter,  this 
being  favoured  by  a  diminution  in  intra-abdominal  tension. 
Hence  a  deep  costal  inspiration  causes  a  flattening  of  the 
belly.  The  scaphoid  appearance  thus  induced  in  a  thin 
subject  is  rendered  more  pronounced  by  the  throwing  for- 
ward of  the  costal  arch,  which  helps  to  cause  the  abdominal 
wall  to  shelve  away  from  it,  and  also  by  the  backward 
movement  of  the  dorso-lumbar  spine  which  accompanies  a 
deep  costal  inspiration. 

The  flattening  of  the  belly  just  described  must  be  care- 


60  .  EESPIRATOKY    EXERCISES 

fully  distinguished  from  that  which  is  due  to  a  voluntary 
contraction  of  the  transverse  fibres  of  the  abdominal  walls. 
This  is  the  kind  of  retraction  advocated  by  those  teachers 
of  singing  who  advise  costal  as  distinguished  from 
abdominal  breathing.  Sir  Morel  Mackenzie  and  others 
have  mixed  up  these  two  varieties  of  retraction.  Mackenzie 
assumed  that  the  retraction  of  the  belly  observed  in  divers 
before  diving,  and  in  those  about  to  make  a  strong  effort,  is 
a  primary  event,  akin  to  the  retraction  adopted  by  singers ; 
whereas  it  is,  in  point  of  fact,  a  secondary  event — the  result 
of  a  deep  costal  inspiration. 

Costal  and  abdominal  breathing  may  be  associated.  After 
a  full  pancostal  breath,  it  is,  as  we  shall  see,  doubtful 
whether  in  the  normal  individual  any  additional  air  can  be 
inspired  by  means  of  the  diaphragm ;  the  quantity  must  in 
any  case  be  small.  While,  however,  after  such  an  inspira- 
tion abdominal  breathing  is,  in  the  normal  individual, 
practically  impossible,  it  is,  in  a  limited  degree,  possible  after 
an  incomplete  inspiration  of  this  kind. 

Abdominal  breathing  may,  in  a  similar  way,  be  asso- 
ciated with  lower  costal  breathing,  and  here  also  the 
abdominal  breath  is  limited.  The  fact  is  that  expansion 
of  the  lower  bony  thorax  causes  a  flattening  of  the  dia- 
phragm which  necessarily  entrails  the  range  of  abdominal 
breathing.  Nevertheless,  lower  costal  and  abdominal 
breathing  may  be  associated  in  varying  degrees  ;  thus,  a 
complete  lower  costal  breath  may  be  associated  with  a 
moderate  abdominal  breath,  and,  again,  an  almost  complete 
abdominal  inspiration  with  moderate  lower  costal  expansion. 

The  Quantity  of  Air  that  can  be  expired  by  Different  Methods 
of  Breathing. — The  total  quantity  of  air  that  can  be  expired 
after  the  fullest  possible  inspiration  is  termed  the  '  vital 
capacity.'  This  subject  will  Ije  dealt  with  in  a  separate 
chapter.     Here  it  will  l)e  convenient  to  note  the  quantity 


MODES    IN    WHICH    THE    THORAX    IS    ENLARGED      61 

of  air  that  can  be  expired  by  the  different  methods  of 
breathing.  The  subjoined  table  gives  the  results  obtained 
by  the  spirometer  in  my  own  case.  I  must  mention,  how- 
ever, that  it  is  extremely  difficult  to  make  accurate  observa- 
tion on  this  head,  because  it  is  by  no  means  easy  to  breathe 
by  any  particular  method  without  encroaching  on]  another. 
Thus,  in  pure  abdominal  breathing  we  must  be  absolutely 
certain  the  ribs  do  not  move ;  the  result  in  this  case,  more- 
over, depends  upon  the  degree  of  expansion  of  the  bony 
thorax  while  the  abdominal  breath  is  being  taken.* 

Table  showixg   the    Quantity  of  Air  which   can  be  expired  by 
THE  Different  Methods  of  Breathing. 

Pancostal    400  cub.  in. 

Lotver  costal       210  cub.  in. 

This  can  be  extended  by  allowinff  the  inner  ends  of  the  clavicles  to  move 
upwards,  and  by  varying  the  elevation  of  the  entire  clavicles. 

Loivcr  costal,  siq^plemetited 

htj  ahdominal 210  to  270  cub.  in. 

According  to  the  degree  of  diaphragmatic  descent. 

Ahdominal Thorax  kept  fixed  in 

its  mean  position       110  cub.  in. 
Thorax  kept  fixed  in 
position   of   costal 

expiration 170  cub.  in. 

Thorax  kept  fixed  in 
lower  costal  ex- 
pansion             90  cub.  in. 

Ahdominal,     supplemented 

hy  lower  costal  expansion     110  to  270  cub.  in. 

According  to  the  degree  of  lower  costal  expansion. 

200  cubic  inches  are  inspired  by  a  full  abdominal  breath,  making  no 
effort  to  prevent  expansion  of  the  lower  chest,  nor  to  cause  it,  the  ribs  not 
passing  beyond  the  mean  in  expiration. 

*  For  these  and  other  reasons  I  cannot  but  receive  the  figures  which 
have  been  published  relative  to  this  question  with  some  reserve.  To 
mention  only  one  instance,  JoaP  gives  the  abdominal  and  costal  respi- 
ratory capacities  of  tliree  experienced  singers  as  follows  : 

Abdominal.  Costal. 

5,200  c.c 5,300  c.c. 

4,300    „  4,800   „ 

4,000   „  4,300    „ 

In  the  first  case,  that  is  to  say,  the  proportion  is  as  52  :  53.  I  have 
no  doubt  whatever  that  in  this,  and  indeed  in  all  three  cases,  the 
abdominal  inspiration  was  supplemented  by  a  lower  costal  breath ; 
otherwise  the  disproportion  would  be  very  much  greater. 


1  '  On   Eespiration  in  Singers,'  tianslatcd  by  Ncnis  Wolfenden,  p.  80. 


62  RESPIRATORY   EXERCISES 

It  will  be  seen  from  the  above  that  pure  abdominal 
breathing  gives  a  very  small  volume  of  air,  but  that  if  this 
method  is  supplemented  by  lower  costal  inspiration,  as  it 
practically  alwa3'S  is,  it  may  give  as  large  a  volume  as  the 
latter  method. 

It  will  also  be  observed  that  the  quantity  of  air  that  can 
be  inspired  by  descent  of  the  diaphragm,  i.e.,  by  abdominal 
breathing,  varies  according  to  the  degree  of  expansion  of 
the  lower  bony  chest.  The  more  expanded  this  is,  the 
nearer  are  the  circumferential  attachments  of  the  dia- 
phragm to  the  level  of  the  central  tendon — i.e.,  the  flatter  is 
the  diaphragm,  and  the  less  is  its  inspiratory  power. 
Contrariwise,  the  more  contracted  the  lower  bony  chest,  the 
more  arched  is  the  diaphragm  and  the  greater  its  inspiratory 
power.  Hence  I  find  that  when  my  thorax  is  fixed  in  full 
lower  costal  expansion  I  can  only  inspire  90  cubic  inches  by 
descent  of  the  diaphragm,  while  by  the  same  means  I  can 
inspire  nearly  double  the  amount  (170  cubic  inches)  when  it  is 
fixed  in  a  position  of  extreme  costal  expiration.  When  it  is 
fixed  in  the  mean  position  110  cubic  mches  can  be  taken  in 
by  an  abdominal  breath.  The  170  cubic  inches  represent 
the  amount  that  can  be  inhaled  when  the  circumference  of 
the  diaphragm  is  lowered  down  to  the  fullest  possible  extent 
below  the  central  tendon,  when  that  tendon  is  arched  to  its 
utmost,  and  when,  therefore,  the  greatest  increase  in  thoracic 
capacity  can  l^e  effected  by  its  contraction.  The  90  cubic 
inches  represent  the  quantity  of  air  that  can  be  inspired 
when  the  diaphragm  is  flattened  by  the  extreme  opening 
out  of  the  costal  arch  and  thus  rendered  less  capable  of 
increasing  thoracic  capacity. 

If,  after  a  complete  expiration,  a  full  diaphragmatic 
breath  be  taken,  it  will  be  found  that  it  is  still  possible  to 
take  in  a  large  draught  of  air.  The  same  is  true  if  a  lower 
costo-diaphragmatic  breath  be  taken  instead  of  a  diaphrag- 


MODES    IN    WHICH    THE    THORAX    IS    ENLARGED      G3 

matic,  though  in  this  case  the  amount  of  air  that  can  be 
subsequently  inhaled  is  less.  If,  on  the  other  hand,  a  full 
pancostal  inspiration  be  taken  after  a  complete  expiration, 
no  more  air,  or  at  all  events  only  a  small  quantity,  can  be 
inhaled  by  means  of  the  diaphragm.*  In  other  words,  the 
lungs  in  the  normal  individual  are  not  large  enough  to  fill 
the  thorax  at  its  potential  maximum,  i.e.,  with  the  ribs 
elevated  and  the  diaphragm  depressed  to  their  respective 
extremes.  I  say  in  the  normal  individual,  by  which  I  mean 
one  with  freely  movable  ribs  and  healthy  lungs.  If  the 
ribs  are  not  freely  movable,  so  as  to  allow  of  a  deep  costal 
inspiration,  the  individual  may  be  able  to  take  an  appre- 
ciable abdominal  breath  after  he  has  raised  the  ribs  to  the 
utmost.  Similarly,  in  large-lunged  emphysema,  the  lungs 
may  be  large  enough  to  admit  of  considerable  abdominal 
breathing  after  a  full  pancostal  inspiration. f 

*  This  at  once  disposes  of  the  view,  held  by  some  teachers  of  sing- 
ing, that  more  air  can  be  taken  in  by  a  diaphragmatic  or  lower  costo- 
diaphragmatic  breath  than  by  the  purely  costal  method.  Fm-ther  proof 
of  the  fallacy  of  this  teaching  is  supplied  b^-  the  spirometer. 

t  It  has  been  suggested  to  me  that  the  lungs  are  large  enough  to 
fill  the  chest  when  expanded  to  its  potential  maximum,  and  that  the 
inability  to  take  in  an  ample  supply  of  air  by  means  of  the  diaphragm, 
after  a  full  costal  inspiration,  is  not  due  to  the  lungs  having  been 
stretched  to  their  limits,  but  to  the  diaphragm  having  been  flattened  to 
the  utmost  by  the  lower  costal  expansion.  I  cannot  accept  this  view. 
Air  can  be  inspired  when  the  costal  arch  is  opened  out  to  its  utmost  by 
a  lower  costal  inspiration.  In  emphysema,  again,  the  bony  chest  may 
be  in  a  state  of  superextraordinary  inspiration,  and  the  diaphragm  yet 
retain  considerable  inspiratory  power.  It  is  true  that  in  very  advanced 
cases  of  hypertrophous  emphysema  the  respiratory  capacity  of  the 
diaphragm  is  greatly  curtailed,  and  may  possibly  in  some  cases  be 
quite  annulled.  Nevertheless,  if  we  except  such,  I  beUeve  that  the 
potential  capacity  of  the  chest  is  always  greater  than  that  of  the  lungs, 
and  that  the  expansibility  of  these  organs  essentially  determines  the 
limit  to  which  the  thorax  can  be  enlarged.  This  position  is  strengthened 
by  what  we  observe  in  destructive  puhuonary  disease,  which  alway 
diminishes  thoracic  expansibility. 


CHAPTER  X. 

BREATHING  IN  SINGERS. 

The  various  methods  of  breathing  which  have  been  recom- 
mended for  singers  are  not  always  very  lucidly  expounded, 
but  they  may,  I  think,  be  described  under  one  or  other  of 
the  following  heads  : 

1.  Clavicular ;  when  the  clavicles  are  raised,  and  the 

expansion  in  the  upper  part  of  the  chest  is  in 
relative  excess, 

2.  Pure  lower  costal:  when  the  lower  ribs  are  raised, 

without  any  protrusion  of  the  belly,  the  clavicles 
being  kept  fixed.  A  sub  variety  of  this  is  that  in 
which  the  inner  ends  of  the  clavicles  are  moved 
upwards  and  forwards,  thus  securing  an  increased 
expansion  of  the  upper  part  of  the  chest. 

3.  Lower  costo-abdominal :    when   the   lower  ribs   are 

raised,  and  the  belly  protruded,  the  former  being 
the  essential  movement. 

4.  Pure  abdominal :  when  the  belly  is  protruded,  the 

ril)S  Iteing  fixed. 

5.  Abdomino-costal :  when  the  l^elly  is  protruded,  and 

the  lower  riljs  raised,  the  former  being  the  essen- 
tial factor. 
1.  Clavicular  Breathing. — In  this  the  clavicles  are  raised, 

and  the  expansion  of  the  upper  part  of  the  chest  is  in 

relative  excess.* 

*  Nothing  better  shows  the  obscurity  which  prevails  regarding  the 
various  modes  of  breathing  for  singers  than  Joal's  observations  on 
clavicular  breathing.  See  on  this  subject  the  author's  paper  in  the 
Journal  of  Laryngology,  etc.,  1897,  p.  35. 


BREATHING    IN    SINGERS  65 

This  mode  of  breathing  is  practically  impo8sil)le  for  a 
man,  but  many  women  are  undoubtedly,  in  the  sense 
defined  abo\e,  clavicular  breathers,  because  the  lower  chest 
cannot  expand  adequately  when  the  stays  are  worn  tight. 
The  quantity  of  air  they  inspire  by  this  method  is  said  to 
be  less  than  by  the  others.  In  men,  on  the  other  hand, 
raising  the  clavicles  necessitates  a  considerable  expansion 
of  the  entire  bony  chest,  not  of  the  upper  part  only,  and  so 
it  secures  the  maximum  intake  of  air ;  but  this  is  not  the 
classical  clavicular  breathing.  It  might  be  described  as  the 
pancostal  type.  I  conclude,  however,  that,  under  whatever 
name,  it  is  the  method  adopted  by  singers  of  the  old  Italian 
school,  for  some  of  them  executed  passages  exceeding 
ninety-five  seconds,  and  I  do  not  think  it  probable  that 
any  man  could  execute  so  long  a  passage  in  one  breath 
except  by  the  pancostal  method,  i.e.,  by  raising  the  clavicles 
and  all  the  ribs  to  the  utmost.  Joal,  however,  is  of  the 
opinion  that  this  school  adopted  the  lower  costo-abdominal 
method. 

2.  Lower  Costal  Breatking. — In  this  the  clavicles  are  kept 
fixed,  and  the  ribs  are  raised,  expansion  taking  place  chiefly 
in  the  lower  part  of  the  chest,  the  diaphragm  not  descending- 
This  is  the  method,  so  far  as  I  can  understand,  described 
by  Mayo  Collier,  and  recommended  by  him  and  by  the  late 
Sir  Morel  Mackenzie,  though  they  are  silent  as  to  whether 
the  clavicle  should  be  raised  or  not. 

In  this  method  the  abdomen  is  drawn  in  ('  rendered  con- 
cave ')  by  a  contraction  of  the  abdommal  muscles,  and  it  is 
argued  that  thereby  '  the  vault  of  the  diaphragm  is  sup- 
ported by  the  front  abdommal  walls,  and  maintained  in 
position  by  the  liver,  spleen,  and  great  end  of  the  stomach ' 
(p.  94).  In  this  way  the  central  tendon  of  the  diaphragm 
is  fixed,  and  the  contraction  of  the  muscle  fibres  which  pass 
more  or  less  vertically  from  the  central  tendon  above  to  the 


60  RESPIRATORY   EXERCISES 

ribs  below,  spends  itself  in  raising  the  lower  ribs,  and  in 
expanding  the  lower  bony  thorax. 

It  should  be  observed  that  a  very  slight  elevation  of  the 
clavicle  during  a  lower  costal  breath  adds  considerably  to 
the  volume  of  air  that  can  be  inspired,  and  there  can  be  no 
doubt  that  many  singers  who  for  the  most  part  adopt  the 
lower  costal  method,  and  who  would  indignantly  repudiate 
the  accusation  of  being  clavicular  breathers,  do  appreciably 
elevate  the  clavicles,  especially  when  desirous  of  taking  a 
more  than  usually  deep  breath. 

3.  Lower  Costo-Abdominal  Breathing. — In  this  variety  the 
lower  costal  breathing  is  combined  with  varying  degrees  of 
abdominal  breathing,  but  the  latter  is  subsidiary  to  the 
former,  and  only  occurs  in  comparatively  slight  degree, 
causing  a  moderate  protrusion  of  the  epigastrium.  It 
should  be  mentioned  that  some  degree  of  epigastric  protru- 
sion is  apt  to  occur  whenever  a  deep  costal  inspiration  is 
taken.  This  may  result  from  two  causes  :  either  from  an 
active  descent  of  the  diaphragm,  or  from  an  elevation  of 
the  lower  end  of  the  sternum  above  the  central  tendon  of 
the  diaphragm,  causing  the  heart  to  lie  immediately  under 
the  epigastric  wall. 

This,  as  I  understand  him,  is  the  method  of  breathing 
advocated  by  M.  Joal,  though  he  does  not  make  it  abso- 
lutely certain  whether  he  recommends  actual  descent  of 
the  diaphragm,  merely  remarking  that  '  the  convexity  of 
the  diaphragm  tends  to  be  effaced.'*  The  belly,  he  con- 
tends, should  be  retracted  in  the  subumbilical  region,  and 
while  the  clavicles  are  kept  fixed  the  ril)s  are  elevated  to 
their  fullest  extent  and  the  epigastrium  protruded  (pre- 
sumably from  active  descent  of  the  diaphragm).  The 
retraction  of  the  subumbilical  region  he  refers  to  a  volun- 
tary contraction  of  the  inferior  fasciculi  of  the  abdominal 

*  *0n  Respiration  in  Singers,'  translated  by  Norris  Wolfenden,  p.  HO. 


BREATH IXG    IN"    SINGERS  *  ()7 

muscles  (p.  117),*  and  its  object  is  to  support  the  dia- 
phragm below,  so  as  to  enable  the  entire  force  of  its  con- 
traction to  be  devoted  to  the  elevation  of  the  lower  ribs,  as 
already  described.  To  the  same  end  some  singers  com- 
press the  belly  by  means  of  a  band  or  belt.  This  form  of 
breathing  Joal  somewhat  ambiguously  designates  the 
'  costal '  type,  and  he  gives  it  his  enthusiastic  support.  In 
it  he  assumes  the  upper  ribs  to  be  stationary ;  but  it  is 
certain  that  fixation  of  the  clavicle  by  no  means  prevents 
expansion  of  the  upper  chest,  as  anyone  may  see  for  him- 
self who  will  examme  the  bare  chest  while  a  full  costal 
breath  is  being  taken  with  fixed  clavicles. 

It  is  contended  by  Joal  that  this  method  of  breathing 
secures  a  larger  volume  of  air  than  the  others  by  expand- 
ing the  chest  in  its  most  roomy  part.  This  is  not  my 
experience. 

A  method  of  breathing  taught  in  Italy  and  described  by 
Cathcart  may  be  mentioned  here,  in  that  it  is  allied  to 
Joal's  method.  The  outer  ends  of  the  clavicles  are  fixed, 
the  inner  extremities  moving  upwards  and  forward.  In 
this  way  not  only  is  the  superior  entrance  to  the  thorax 
enlarged,  but  the  bony  chest  is  enabled  to  expand  amply  in 
its  upper  as  well  as  in  its  lower  part.  Indeed,  what  is  aimed 
at  is  producing  the  maximum  expansion  above. 

4.  Pure  Abdominal  Breathing. — In  this  the  breathing  is, 
as  far  as  possible,  purely  al)clominal ;  i.e.,  the  diaphragm 
•contracts  with  relaxed  abdominal  walls,  and  being  thus  only 
slightly  supported  on  its  under  surface,  the  force  of  its  con- 
traction is  chiefly  spent  in  thrusting  the  abdominal  viscera 
downwards,  and  in  increasing  the  vertical  capacity  of  the 

*  It  is  due,  I  believe,  to  a  contraction  of  the  transversely  disposed 

muscle  fibres  of  the  anterior  abdominal  wall,  as  already  described ;  a 

contraction  of  the  lower  portions  of  the  recti  would  tend  to  pull  down 

the  ribs  and  sternum,  which  are  requu-ed  to  be  raised  in  the  form  of 

breathing  under  discussion. 

5-2 


68  RESPIRATORY    EXERCISES 

chest,  and  to  only  a  small  extent  in  an  upward  tug  on  the  ribs 
(which  are  probably  prevented  from  being  raised  by  a  con- 
traction of  certain  muscles,  such  as  the  quadrati  lumborum 
and  the  serrati  postici  inferiores).  At  all  events,  while  con- 
traction of  the  diaphragm  tends  to  raise  the  ribs,  even  with 
relaxed  abdomen,  there  can  be  no  doubt,  as  Mandl  observes, 
that '  when  the  person  is  completely  master  of  diaphragmatic 
respiration,  deep  inspirations  can  be  taken  without  elevating 
the  ribs  in  any  manner,  as  Magendie  had  already 
said.'* 

Abdominal  breathing  is  closely  associated  with  the  name 
of  Mandl,  who  in  1855  advocated  this  mode  of  breathing  in 
an  article  which  appeared  in  the  Gazette  Medicale,  though 
it  had  already  been  largely  practised.  He  obtained  a 
wide  following,  and  in  schools  of  singing  most  strange 
devices  were  resorted  to  for  the  purpose  of  fixing  the  ribs 
and  compelling  pure  abdominal  breathing ;  thus,  the 
*  pupils  were  made  to  sing  while  lying  down  on  mattresses, 
sometimes  with  weights,  more  or  less  heavy,  placed  on  the 
sternal  region ;  masters  were  even  said  to  make  a  practice 
of  seating  themselves  familiarly  upon  the  chests  of  their 
pupils.  In  the  schools  were  to  be  seen  gallows  with 
thongs  and  rings  for  binding  the  upper  half  of  the  body, 
orthopnidic  apparatus,  rigid  corsets,  and  a  kind  of  pillory 
which  enclosed  the  frame  and  fixed  the  ribs.'t 

Abdominal  breathing  is  said  to  be  rarely  employed  by 
women.  Joal  has  not  met  with  a  single  woman  singer  who 
adopts  this  method.  Nor  is  this  surprising,  when  we  reflect 
that  the  corset  interferes  with  the  abdominal  protrusion. 
But,  indeed,  this  method  is  probably  very  rarely  employed 
at  all — I  doubt  if  it  ever  is,  pure  and  simple.  I  cannot 
believe  that  Mandl  and  his  school  confined  themselves  tO' 
pure  abdominal  l>reatliing. 

*  Joal,  o^j.  clt.,  p.  67.  t  Ibid.,  p.  43. 


BREATHING    IX    SINGERS  69 

5.  Abdomino-Costal  Breathing^. — When  abdominal  is  supple- 
mented by  costal  breathing,  -we  may  term  it'  abdomino-costal.' 
It  is  the  method  recommended  by  Lennox  Browne  and 
Behnke  in  their  work  on  '  Voice,  Song,  and  Speech.' 

I  now  propose  briefly  to  criticise  these  various  modes 
of  breathing,  with  a  view  to  discover  which  is  the  most 
suitable  for  the  singer.  I  must  at  once  confess  that  I 
do  not  at  present  see  my  way  to  recommend  very  specially 
any  one  method  to  the  exclusion  of  the  others.  What  I 
have  been  most  concerned  to  do  is  to  define  accurately  the 
different  modes  in  which  breathing  may  be  carried  on,  and 
to  clear  the  ground  for  profitable  discussion. 

Practically,  all  writers  condemn  forced  clavicular  breathing 
in  the  case  of  the  man,  but  there  are  some  who  justify  its 
employment  in  the  woman,  on  the  erroneous  assumption 
that  it  constitutes  for  her  the  normal  type  of  breathing. 
Its  evils  are  self-evident,  necessitating  as  it  does  elevation 
of  the  shoulders,  and,  from  the  contraction  of  the  cervical 
muscles,  compression  of  the  important  structures  entering 
the  thorax  from  above.  The  effort  of  lifting  with  every 
inspiration  the  entire  thorax  and  upper  extremities  is 
tiriag.;  the  interference  with  the  return  of  blood  from  the 
head  during  a  loud  and  long-sustained  note  may  be  so  great 
as  to  cause  t_urbidity^  and  even  duskiness,  of  the  face ;  and 
it  is,  moreover,  doubtful  whether  expiration  can  be  so 
nicely  regulated  as  by  the  other  methods.  If  pronounced 
clavicular  breathing  is  ever  justifiable,  it  should  certamly 
only  be^mployed  on  rare  occasions,  and  as  an  extension  of 
the  more  usual  form  of  breathing. 

It  is  otherwise,  however,  with  modified  clavicular  breathing. 

I  can  see  no  objection  to  a  moderate  upward  and  forward 

movement  of    the  inner  ends  of  the  clavicles,  as  recom- 

'  mended  by  Cathcart.     This  not  only  enlarges  the  superior 


70  RESPIRATORY    EXERCISES 

opening  of  the  thorax,  but  favours  the  expansion  of  the 
upper  portions  of  the  chest,  where,  it  is  contended,  ample 
expansion  should  be  aimed  at  on  the  ground  that  the 
nearer  the  resonating  cavity  is  to  the  seat  of  voice-produc- 
tion, the  better  resonance  does  it  give. 

It  is  certain  that  moderate  clavicular  breathing  is 
frequently  emploj^ed  by  those  who  claim  to  be  lower-chest 
breathers,  and  it  seems  at  least  doubtful  whether  the  singer 
should  rigidly  adhere  to  the  hard  and  fast  rule  never  to 
raise  the  clavicles  in  the  slightest  degree. 

Accepting,  then,  the  dictum  that  pronounced  clavicular 
breathing  can  only  be  justifiable  on  rare  occasions,  we  have 
to  inquire  which  of  the  other  methods  is  the  best.  Is  it  (a) 
the  pure  lower  costal ;  or  (h)  this  extended  by  abdominal 
breathing  (and  if  this  form,  how  much  abdominal  extension 
is  justifiable) ;  or  (c)  the  pure  abdominal ;  or,  finally,  (d) 
the  abdominal,  extended  by  the  lower  costal  (and  if  the 
latter  form,  how  much  lower  costal  is  justifiable) "? 

In  seeking  an  answer  to  our  question,  we  of  course  attach 
some  weight  to  the  amount  of  air  that  can  be  inspired  by 
the  various  methods,  but  not  too  much.  The  singer  is  not 
required  to  distend  his  chest  to  the  utmost.*  Were  a 
large  volume  of  air  the  great  desideratum,  then  a  pancostal 
breath,  with  extreme  elevation  of  the  clavicles,  would  be 
best,  for  by  it  half  again  as  much  air  can  be  inspired  as 
by  any  other  method. 

It  is  urged  that  the  lower  costo-abdominal  method  is 
superior  to  the  abdominal,  in  that  the  work  is  shared  by  a 
larger  number  of  muscles,  for  in  abdominal  breathing  these 
are  more  or  less  confined  to  the  diaphragm  and  the  abdominal 
muscles.  Speaking  from  my  own  experience,  I  should  say 
that  the  very  reverse  is  the  case  :  an  abdominal  breath  can 

*  Joal  argues  as  if  it  were  necessary  to  take  in  a  ^•cry  large  volume 
of  air.     Sec  op.  cit.,  pp.  72,  80,  134. 


BREATHING   IN   SINGERS  71 

be  taken  with  the  utmost  ease,  while  a  lower  costal  breath 
involves  an  appreciable  effort,  seeing  that  the  ribs  have  not 
only  to  be  raised  but  also  to  be  bent. 

It  is  also  argued  that  in  the  abdominal  method  expiration 
requires  the  expenditure  of  more  energy  than  in  the  lower 
costal  variety,  in  order  to  push  up  ihe  viscera,  which  are 
displaced  downward  by  the  descent  of  the  diaphragm — an 
argument  of  no  weight,  seeing  that  these  organs  are  capable 
of  resuming  their  normal  position  upon  mere  relaxation  of 
the  diaphragm  without  any  contraction  of  the  abdominal 
muscles,  being  drawn  up  by  the  elastic  recoil  of  the  lungs. 

We  have  next  to  inquire  whether  the  abdominal  or  the 
costal  method  enables  the  singer  to  regulate  the  outgoing 
blast  of  air  with  the  greater  precision  and  nicety.  The 
air,  as  we  know,  has  to  be  driven  out  slowly,  steadily 
{i.e.,  without  jerks),  and  with  varying  degrees  of  intensity. 

How  is  this  regulation  effected  ?  Cathcart  contends  that 
in  the  case  of  costal  breathing  it  is,  or  should  be,  effected 
by  the  mutual  antagonism  between  the  expiratory  muscles 
and  the  false  vocal  cords,  which  approximate  in  order  to 
oppose  the  outgoing  blast  of  air,  and  he  attaches  great 
importance  to  this  laryngeal  impediment,  seeing  that  with- 
out it  (so  he  argues)  it  would  be  impossible  to  get  that 
degree  of  condensation  of  pulmonary  air  necessary  to 
bring  out  the  best  quality  of  tone.  It  is,  however,  more 
generally  held  that  the  regulation  of  the  expiratory  blast  is 
essentially  dependent  upon  the  antagonistic  action  of  the 
inspiratory  and  expiratory  muscles,  and  this  is  probably  the 
ease  in  abdominal  and  in  pronounced  clavicular  breathing. 
Cathcart  holds  that,  in  the  form  of  breathing  he  recom- 
mends, the  inspirators  cease  to  contract  when  expiration 
begins,  the  air  being  held  by  the  false  vocal  cords ;  but 
according  to  the  prevailing  view  the  inspirators  continue  in 
action,  though  with  diminishing  force,  throughout  the  entire 


72  RESPIRATORY   EXERCISES 

period  of  expiration,  no  matter  what  mode  of  breathing  is 
adopted.  Of  the  two  sets  of  muscles,  however,  it  is  held 
that  the  expirators  act  the  more  powerfully,  and  thus  expel 
the  air,  the  force  of  expulsion  and  consequent  loudness  of 
note  depending  upon  the  degree  of  excess  of  inspiratory  over 
expiratory  action.  In  delivering  a  note  fortissimo,  for 
instance,  the  expirators  act  with  full  force,  the  inspirators 
undergoing  considerable  relaxation.* 

Now,  it  is  urged  that  much  better  control  can  be  exercised 
over  the  expiratory  blast  by  the  costal  than  by  the  abdominal 
method,  which,  according  to  Cheval,  Morel  Mackenzie,  and 
others,  is  apt  to  give  a  jerky  note,  from  the  inability  of  the 
diaphragm  to  undergo  a  gradual  and  even  relaxation.  This 
is,  of  course,  a  question  for  experience  to  decide,  but  I  see 
no  theoretic  reason  why  the  diaphragm  should  not  be 
taught  to  relax  gradually  as  well  as  other  muscles.  Indeed, 
this  argument  regarding  the  inability  of  the  diaphragm  to 
undergo  gradual  and  even  relaxation  may  be  employe(J 
against  the  lower  costal  method,  seeing  that  the  supporters 
of  it  contend  that  the  diaphragm  is  an  important  agent  in 
expanding  the  lower  bony  chest. 

Cathcart  contends  that  by  his  method  the  air  is  driven  out 
of  the  lower  regions  of  the  langs  faster  than  from  the  upper 
lobes,  and  that  'the  upper  ribs  will  only  be  pulled  down 
when  the  lower  lobes  are  nearly  exhausted,  and  it  is  then 
time  to  renew  the  breath.'  In  this  way,  he  argues,  the 
high  resonating  properties  of  the  expanded  upper  chest  are 
maintained  throughout  expiration.  I  have  not  yet  had  the 
opportunity  of  testing  the  accuracy  of  this  view;  I  will 
only  here  observe  that  the  upper  ribs  must  to  a  large  extent 
follow  the  lower. 

It  has  been  further  urged  that  abdominal  breathing 
may  induce   serious   disturbances  in  the  abdomino-pelvic 

*  .Joal,  op.  cit.,  p.  97. 


BREATHING   IN   SINGERS  73 

viscera.  In  this  method  the  diaphragm  descends  to  its 
furthermost  limit,  and  remains  contracted  throughout 
nearly  the  entire  period  of  expiration,  during  which  time 
the  abdominal  muscles  are  contracted  also,  in  order  to 
expel  the  air.  This  leads  to  considerable  compression  of 
the  abdominal  and  pelvic  organs,  and,  according  to  Cheval,* 
all  sorts  of  troubles  may  thus  result,  such  as  hernias, 
indigestions,  and  disorders  of  the  abdominal  circulation. 
Joal  describes  the  case  of  a  woman  at  twenty-two,  who  was 
in  perfect  health  and  '  able  to  sing  with  impunity  up  to  the 
day  when  she  fell  into  the  hands  of  a  fanatical  professor  of 
abdominal  respiration,'  after  which  dysmenorrhoea,  which 
was  found  to  depend  upon  retroversion  of  the  uterus,  set  in 
(p.  74).  In  another  case  the  most  violent  form  of  dyspepsia 
was  similarly  induced.  He  quotes  from  other  authors  to 
the  same  effect,  and  refers  to  a  case  of  uterine  prolapse  as 
resulting  from  the  abdominal  method  of  breathing.  Now, 
I  can  quite  understand  that  this  form  of  breathing  might 
bring  al)out  some  of  these  evils  in  women  who  tight-lace, 
but  I  find  it  hard  to  believe  that  it  can  be  injurious  to  the 
normal  woman  who  does  not  compress  the  waist  and 
abdomen. 

A  further  argument  has  been  advanced  in  favour  of  costal 
breathing,  whether  the  lower  costal,  as  advocated  by  Joal, 
or  that  more  extended  form  recommended  by  Cathcart,  in 
which  the  upper  chest  is  well  expanded,  i.e.,  that  it  increases 
the  resonance  of  the  bony  thorax ;  and  if  such  is  the  case,  it 
should  go  a  long  way  to  turn  the  balance  in  its  favour.  I 
am  aware  that  theoretic  considerations  appear  to  support 
this  view,  and  it  is  said  to  be  borne  out  by  practical  expe- 
rience, but  I  should  like  definite  proof  of  this. 

One  word  as  to  the  desirability  of  voluntarily  retracting 
the  belly  in  lower  costal  breathing.     I  confess  I  am  some- 

*  Joal,  p.  74. 


74  RESPIRATORY   EXERCISES 

what  doubtful  as  to  the  utility  of  it.  I  think  it  highly 
doubtful  whether  the  diaphragm  plays  an  important  part 
in  elevating  the  lower  ribs  in  this  type  of  breathing.  In 
my  experience  the  ribs  can  be  equally  well  raised  with 
flaccid  belly.  It  does  not  seem  to  me  improbable  that 
abdominal  retraction  was  originally  advocated  in  order  to 
render  abdominal  breathing  impossible. 

Note. — In  response  to  a  request,  my  friend  Dr.  George  C.  Cathcart  has 
briefly  set  forth  his  views  regarding  the  proper  method  of  breathing  for 
smgers  :  '  Breathing  for  singing  differs  from  ordinary  breathing  in  that 
the  chest  has  to  be  used  not  only  as  a  reservoir  for  the  air  which  vibrates 
the  vocal  cords,  but  also  as  a  resonator  of  the  voice.  When  we  remember 
that  the  effectiveness  of  a  resonator  increases  with  its  nearness  to  the 
sound  it  resonates,  it  will  at  once  be  seen  what  an  important  part  the 
mode  of  breathing  plays  in  proper  voice  production.  The  abdominal 
method  originally  introduced  by  Mandl  makes  no  use  of  the  chest  as 
a  resonator.  This  method,  combined  with  lower  costal,  as  advocated 
by  Brown  and  Behnke,  is  little  better,  as  it  also  ignores  the  use  of  the 
chest  as  a  resonator.  In  the  old  Italian  method  the  chest  was  raised , 
as  a  whole,  every  effort  being  made  to  cause  the  maximum  expansion 
of  the  upper  part,  the  inner  ends  of  the  clavicles  being  raised  and  the 
abdomen  retracted.  In  this  waj^  not  only  can  a  large  volume  of  air  bo 
taken  in,  but  the  resonator  is  brought  as  near  as  possible  to  the  vocal 
cords.     This  method  is  in  accordance  with  nature,  science,  and  art.' 


CHAPTER  XL 

VITAL  CAPACITY. 

'  ^'ITAL  CAPACITY  '  IS  the  term  which  John  Hutchinson 
employed  to  denote  the  amount  of  air  that  can  be  expired 
after  the  fullest  possible  inspiration.  After  testing  the 
vital  capacity  of  a  large  number  of  individuals,  he  estimated 
its  average  for  persons  5  feet  in  height  at  174  cubic  inches, 
with  an  increase  of  8  cubic  inches  for  every  inch  above  this. 
Arnold's  estimate  for  5  feet  is  about  the  same,  but  he  gives 
the  increase  for  every  inch  in  height  above  this  as  about 
94-  inches.  Hence,  according  to  Hutchinson,  a  man  of  6  feet 
should  breathe  270  cubic  inches,  while  according  to  Arnold 
it  would  be  288  cubic  inches. 

This  relation  between  height  and  vital  capacity  is  remark- 
able, since  height  is  determined  chiefly  by  length  of  legs, 
and  not  by  the  size  of  the  trunk  and  the  thorax.  People 
of  5  feet  0  inches  in  height  and  those  of  6  feet  have  much 
the  same  length  of  trunk,  and  therefore  the  same  length  of 
thorax ;  nor  is  there  necessarily  any  increase  in  the  chest 
circumference  with  increased  height.  Indeed,  short  men 
have  often  much  greater  thoracic  girth  than  tall  men. 
Hence,  there  is  no  necessary  relation  between  chest  capacity 
and  height,  but  between  vital  capacity  and  height  there 
practically  always  is.*  This  is  due  to  the  fact  that  the 
mohiliti/  of  tJtc  chest  increases  iritli  the  stature. 

*  Hutchinson  determined  the  cubical  contents  of  the  thorax  by 
removing  the  heart  and  lungs  through  an  opening  sufficiently  large  to 


76  RESPIRATORY   EXERCISES 

Hutchinson  further  held  that  there  is  also  no  relation 
between  the  circumference  of  the  chest  and  vital  capacity, 
a  tall  man  with  a  chest  of  34  girth  probably  having 
a  larger  vital  capacity  than  a  short  man  with  a  40  inch. 
But  of  course,  with  equal  mobility,  the  greater  the  circum- 
ference, the  greater  the  vital  capacity. 

Arnold,  on  the  other  hand,  finds  a  definite  relation 
between  thoracic  girth  and  vital  capacity.  He  gives  160 
cubic  inches  as  the  standard  capacity  of  a  thoracic  girth  of 
26  inches,  and  9  inches  the  increment  in  capacity  for  every 
increase  of  1  inch  in  girth. 

Other  formulae  are  given  by  which  it  is  claimed  that  the 
normal  vital  capacity  of  an  mdividual  may  be  calculated. 
Thus,  Wintrich  has  sought  to  find  a  coefficient  which, 
multiplied  by  the  height,  should  give  the  normal  vital 
capacity ;  C.  W.  Miiller  calculates  it  from  the  length  of  the 
trunk  and  the  circumference  of  the  chest,  and  Arnold 
from  the  total  height  and  the  circumference  of  the  chest. 
All  such  formulae  are  untrustworthy. 

For  the  same  height  the  vital  capacity  is  much  less  in 
women  than  in  men.  Waldenburg  estimates  the  former  at 
from  three-quarters  to  two-thirds  that  of  the  latter,  and 
Arnold  found  the  increase  with  every  inch  of  stature  as  two- 
thirds  that  of  men. 

According  to  Wintrich,  vital  capacity  goes  on  increasing 
up  to  the  age  of  forty ;  according  to  Arnold,  up  to  thirty- 
five.  Hutchinson  found  an  increase  up  to  thirty,  and  a 
diminution  of  1^  inches  with  every  subsequent  year  up  to 
sixty.     In  old  age  vital  capacity  sinks  to  a  very  low  level. 

admit  the  hand,  and  subsequently  injecting  it  with  plaster  of  Paris. 
In  this  way  he  was  able  to  obtain  a  cast  of  the  chest,  the  cubical  con- 
tents of  which  could  then  be  readily  ascertained,  and  by  this  means  he 
claimed  to  show  that  vital  capacity  may  be  larger  than  the  mean  cubical 
contents  of  the  chest. 


VITAL    CAPACITY  77 

Those  leading  sedentary  lives  have  a  much  smaller  vital 
capacity  than  the  active.  It  is,  indeed,  surprising  how  fixed 
the  chest  becomes  in  the  sedentary.  Vital  capacity  is 
greater  in  the  standing  than  in  the  sitting  posture,  and 
greater  in  the  latter  than  when  lying  down.  It  is  diminished 
by  obesity,  after  a  heavy  meal,  by  pregnancy,  and  all  other 
conditions  curtailing  the  respiratory  area  or  interfering  with 
the  respiratory  movements. 

The  Practical  Value  of  gauging  Vital  Capacity:  Value  in 
Diagnosis. — Spirometry  is  practically  useless  in  diagnosis 
where  other  means  have  failed,  though  Hutchinson  claimed 
by  this  means  alone  to  have  diagnosed  a  case  of  com- 
mencing phthisis.  All  tables  which  claim  to  give  the 
normal  vital  capacity  for  different  heights   and  different 

chest  measurements  are  approximate  only ;  at  best  they 
can   only   give   an   average   quantity — a    standard   which, 

however  correct  it  may  be  as  the  mean  capacity  of  a 
large  number,  does  not  necessarily  give  us  the  normal 
capacity  of  the  individual.  Individual  capacities  vary  on 
either  side  of  this  mean.  Hence,  one  with  healthy  lungs 
may  fall  below  it,  while  one  with  pulmonary  disease  may 
surpass  it.  If  we  possessed  a  record  of  the  normal  vital 
capacity  of  the  individual  founded  upon  spirometric 
examinations,  the  case  would  be  different ;  then  any 
decided  falling  away  from  this  would  unmistakably  indi- 
cate disease. 

But  while  spirometry  is  useless  for  diagnostic  purposes, 
it  is  of  value  for  ascertaining  the  extent  and  the  progress  of 
disease.  If,  for  instance,  the  vital  capacity  in  a  case  of 
phthisis  is  good,  we  know  that  there  cannot  be  great  destruc- 
tion of  tissue  ;  and,  similarly,  the  degree  of  emphysema 
present  can  be  estimated  with  considerable  accuracy. 
Waldenburg  points  out  that  when  the  emphysematous 
patient   can   breathe   decidedly  more  into   a   chamber  of 


78  RESPIRATORY   EXERCISES 

rarefied  air  than  into  ordinary  air,  the  prognosis  is  l)etter 
than  when  such  is  not  the  case. 

Spirometry  is  also  decidedly  useful  in  indicating  the 
effect  of  treatment.  By  its  means  we  are  able  to  record 
accurately  any  increase  in  the  expansibility  of  the  lungs  or 
the  mobility  of  the  chest. 

The  Quantity  of  Residual  Air. — The  air  which  remains  in 
the  lungs  after  the  fullest  possible  expiration  is  termed  the 
'  residual '  air.  Hutchinson  estimates  it  at  from  30  to  60 
cubic  inches,  Vierordt  at  from  30  to  40.  Waldenburg 
believes  it  to  be  much  more  than  this — to  be,  indeed,  nearly, 
if  not  quite,  double  the  vital  capacity.  He  points  out  that 
several  pints  of  fluid  may  be  drawn  off  from  one  pleura, 
even  when  the  lung  on  the  same  side  is  by  no  means 
entirely  collapsed,  and  when  the  other  lung  is  quite  un- 
affected. Apparently,  however,  he  overlooks  the  fact  that 
when  a  pleura  is  distended  with  fluid  the  corresponding 
side  of  the  chest  is  in  the  inspiratory  position,  and  not  in 
that  position  in  which  the  lungs  contain  residual  air  only, 
i.e.,  the  position  of  expiration. 


CHAPTER  XII. 

SECONDARY  EFFECTS  OF  THE  RESPIRATORY 
MOVEMENTS. 

There  is  a  tendency  to  think  of  the  respiratory  movements 
as  subserving  one  function  only,  namely,  the  aeration  of 
the  blood.  The  fact  is,  however,  far  otherwise.  In 
tlie  first  place,  the  circulation  of  blood  and  lymph  is  pro- 
foundly affected  by  the  thoracic  movements  ;  in  the  second, 
several  important  organs  are  rhythmically  commoted,  and 
their  functions  thus  influenced  in  no  small  degree.  These 
latter  effects  I  will  now  briefly  describe. 

During  diaphragmatic  descent  all  the  movable  abdominal 
and  pelvic  viscera  are  pushed  downwards,  their  dislocation 
during  deep  abdominal  breathing  being  considerable.* 
This  may  be  proved  l)y  placing  the  palm  of  the  hand  upon 
the  perinteum  and  then  taking  a  deep  inspiration,  when  a 
descent  and  increasing  fulness  of  the  perinseum  can  be  felt 
quite  plainly ;  a  sudden  cough  produces  a  strong  impulse 
in   the    same    situation.      The   extent  to  which  the   liver 

*  Sibson  writes  that,  as  a  result  of  diaphragmatic  descent,  '  the  liver, 
stomach,  spleen,  pancreas,  kidneys,  and  all  the  abdominal  organs,  the 
uterus  (the  inspiratory  descent  of  which  has  been  felt  by  Dr.  Frederick 
Bird),  and  all  the  pelvic  viscera,  are  pushed  downwards  during  a  deep 
inspiration  ;  at  which  time  the  permaeuni  protrudes  more  tlian  it  does 
in  the  tranquil  state'  {Med.  Chir.  Traus. ,  xol.  xxxi.,  p.  363).  I  am 
not,  however,  aware  that  there  is  any  proof  that  the  kidneys  and 
pancreas  descend  during  inspiration. 


80  RESPIRATORY    EXERCISES 

descends  in  breathing  has  ah'eady  been  referred  to,  and 
there  can  be  no  doubt  that  these  movements  favour  its 
functional  activity  by  hurrying  on  the  flow  of  blood,  lymph 
and  bile.  The  liver  is,  during  inspiration,  squeezed  between 
the  diaphragm — which  grasps  a  considerable  portion  of  its 
large  convex  surface — and  the  anterior  abdominal  wall,  and 
it  is  manifest  that  this  rhythmical  compression  must  pro- 
foundly modify  the  hepatic  functions.  We  must,  indeed, 
assume  that  the  functions  of  the  abdomino-pelvic  viscera 
are  dependent  for  their  normal  activity  upon  this  rhythmic 
compression  and  dislocation,  so  that  any  interference  with 
the  latter  must  injuriously  affect  the  former. 

The  descent  of  the  diaphragm  causes  a  corresponding 
downward  movement  of  the  heart.  '  The  central  tendon  of 
the  diaphragm,  forming  the  floor  of  the  pericardium,  pre- 
sents an  inclined  plane,  upon  which  the  heart  glides  for- 
wards and  downwards  during  inspiration  under  the  combined 
influence  of  the  descent  of  the  diaphragm  and  the  forward 
movement  of  the  ribs  and  sternum  '  (Sibson).  In  so  doing 
it  stretches  the  pulmonary  artery,  the  ascending  arch  of 
the  aorta,  and  the  great  vessels  coming  off  from  the  arch  ; 
but  it  must  be  remembered  that  the  pericardium  is  reflected 
on  to  the  great  vessels  at  the  base,  being  thence  continuous 
with  the  cervical  fascia.  Hence,  the  downward  movement 
of  the  diaphragm  tugs  upon  these  vessels,  and  is  limited  by 
their  fascial  attachments. 


CHAPTER  XIII. 

INFLUENCE  OF  THE  RESPIRATORY  MOVEMENTS  ON 
THE  CIRCULATION  OF  THE  BLOOD. 

Befoiie  considering  how  the  circulation  is  modified  by  the 
respiratory  movements,  it  is  necessary  to  refer  briefly  to  the 
influences  of  external  pressure  on  the  heart  and  bloodvessels. 

The  susceptibility  of  the  bloodvessels  to  outside  pressure 
depends  essentially,  I  conceive,  upon  the  blood  pressure 
within  them,  and  in  only  a  small  degree — not  mainly,  as 
Michael  Foster  makes  it  appear — upon  the  thickness  of 
their  walls  :  for  were  the  pressure  in  a  blood-capillary  as 
great  as  that  in  the  aorta,  the  compressibility  of  each 
would  be  practically  the  same.  As  it  is,  the  arteries  are 
comparatively  incompressible,  their  walls  being  supported 
by  a  substantial  internal  blood  pressure,  while  the  veins 
are  much  more  compressible,  owing  to  the  lowness  of  the 
pressure  within  them.  "We  must  think  of  the  arteries 
as  comparatively  rigid  rods,  and  of  the  veins  as  flaccid, 
and  partly  or  completely  collapsed. 

It  follows  that  the  venous  circulation  is  much  more 
susceptible  than  the  arterial  to  variations  in  extravascular 
pressure.  A  good  instance  of  the  differing  compressibility 
of  the  arteries  and  the  veins  is  afforded  by  (1)  the  intra- 
abdominal vessels,  (2)  the  intra-thoracic  vessels. 

1.  De  Jager  points  out  that  even  strong  pressure  upon 
the  abdomen   has  very  little   effect   upon  the  abdominal 

6 


82  RESPIRATORY   EXERCISES 

arteries,  while  it  serves  to  express  a  large  quantity  of  blood 
from  the  splanchnic  veins.*  That  the  abdominal  veins  are 
very  susceptible  to  pressure  is  well  shown  by  the  numerous 
experiments  of  Leonard  Hill  with  reference  to  the  influence 
of  gravitation  on  the  circulation.  Thus,  he  has  shown  that 
whenever  from  failure  in  certain  compensatory  mechanisms 
blood  gravitates  into  the  splanchnic  veins  and  the  right 
heart  is  thereby  bereft  of  its  supply,  simple  pressure  upon 
the  abdomen  suffices  to  squeeze  the  blood  out  of  these  veins 
into  the  right  heart  and  so  to  re-establish  the  circulation. 

2.  Slight  modifications  in  extravascular  pressure  are 
sufficient  to  affect  appreciably  the  calibre  of  the  cavas  and 
the  pulmonary  veins,  especially  of  the  former,  in  which  the 
pressure  is  frequently  negative,  while  considerable  modifica- 
tions of  extravascular  pressure  are  needed  to  modify  the 
calibre  of  the  aorta  to  an  appreciable  extent ;  the  pulmonary 
artery,  being  much  less  tense,  is  more  susceptible  than  the 
aorta,  but  much  less  so  than  the  large  intra- thoracic  veins. 

Unlike  the  bloodvessels,  the  susceptibility  of  the  heart  to 
external  pressure  depends  not  only  on  the  intracardiac 
blood  pressure,  but  also  very  largely  upon  the  thickness  of 
the  cardiac  walls.  Thus,  the  right  auricle  is  easily  influenced 
by  external  changes  in  pressure,  having  both  a  low  internal 
blood  pressure  and  thin  walls.  On  the  other  hand,  the 
massive  thick  walls  of  the  left  ventricle  render  it  com- 
paratively independent  of  external  pressure,  especially 
during  systole,  when  the  internal  pressure  is  very  high. 
Modifications  of  external  pressure  affect  the  heart  chiefly 
by  favouring  or  retarding  diastole. 

We  now  turn  to  the  respiratory  movements  in  connection 
with  these  facts.  The  respiratory  movements  influence  the 
blood-circulation  in  a  threefold  manner :  (1)  By  modifying 

*  Journal  of  rinjsiologi/,  vol.  vii.,  p.  202. 


INFLUENCE    ON    THE    CIRCULATION    OF   THE    BLOOD    83 

the  capacity  of  the  intra-pulmonary  portion  of  the  pulmonary 
circuit ;  (2)  by  modifying  the  pressure  upon  the  heart  and 
such  of  the  intra-thoracic  bloodvessels  as  are  outside  the 
lungs,  namely,  the  aorta  and  its  branches,  the  pulmonary 
artery  and  its  extra-pulmonary  branches,  the  innominate 
veins  and  their  branches,  the  venae  cavfe,  the  azygos  veins, 
and  the  pulmonary  veins  ;  (3)  by  modifying  the  intra- 
abdominal pressure. 

1.  With  every  mspiration  the  vessels  of  the  lungs 
expand,  contracting  again  during  expiration,*  the  degree 
of  vascular  expansion  and  contraction  being,  under  ordinary 
circumstances,  in  direct  proportion  to  the  degree  of  inspira- 
tion and  expiration. 

That  the  intra-pulmonary  vessels  should  open  up  when 
the  lungs  expand  and  shrmk  again  when  they  contract, 
seems  natural  enough,  but  the  exact  reasons  for  these 
alterations  in  calibre  are  not  so  easy  to  determine.  During 
inspiration  the  pressure  in  the  alveoli  falls,  and  that  in  the 
pleurae,  already  negative,  falls  still  further,  so  that  the  effect 
of  inspiration  on  the  lungs  is  much  the  same  as  that  which 
would  be  produced  by  placing  them  in  the  reservoir  of  an 
air-pump  and  then  exhausting  the  air,  having  previously 
ligatured  the  pulmonary  artery  and  vems.  We  know  that 
under  these  circumstances  the  intra-pulmonary  vessels 
would  dilate,  and,  indeed,  the  inspiratory  increase  in  the 
vascular  capacity  of  the  lungs  has  been  attributed  to  a 
species  of  dry  cupping.f  It  must  not,  however,  be  supposed 
that  this  increase  is  due  solely  to  diminution  of  the  atmo- 

*  It  has  been  experiiuentally  sho\vii  that  the  pulmonary  vessels  are 
more  capacious  after  inspiration  than  after  expiration  (see  McKendrick's 
'  Physiology,'  vol.  ii.,  p.  290).  '  If,'  writes  P.  M.  Chapman,  '  at  the 
termination  of  expiration  the  quantity  of  blood  in  the  lungs  is  from 
i'.>"  to  iV"  of  the  total  (Quantity  of  blood  in  the  bod}-,  at  the  termination 
of  inspiration  it  will  be  from  ,V  to  i'...' — Lancet,  1894,  vol.  i.,  p.  587. 

t  See  Michael  Foster's  '  Textbook  of  Physiology,'  sixth  edition. 
Part  II.,  p.  650. 

6—2 


84  RESPIRATORY   EXERCISES 

spheric  pressure  upon  the  bloodvessels.  Such  a  dimmution 
can  only  directly  affect  the  alveolar  vessels,  while  the 
inspiratory  expansion  of  the  intra -pulmonary  vessels  in- 
volves the  whole  of  them.  This  it  does,  I  imagine,  by 
a  diminution  in  the  circumvascular  tissue  pressure.  As 
inspiration  proceeds,  the  fibres — elastic  and  others — sur- 
rounding the  vessels  become  stretched,  and  thus  exert 
traction  upon  and  expand  them.  During  a  complete 
expiration  this  circumvascular  negative  tissue  pressure 
becomes  converted  into  a  positive  pressure,  when  the 
vessels  are  actually  compressed  by  the  surrounding  tissues. 

These  two  pressures,  namely,  the  intra-alveolar  atmo- 
spheric pressure  and  the  circumvascular  tissue  pressure, 
may  be  made  to  vary  within  wide  limits.  When  a  forced 
inspiration  is  taken  with  closed  glottis,  they  both  fall ; 
hence  the  intra-pulmonary  vessels  suffer  a  considerable 
expansion,  and  blood  is  sucked  in  large  quantities  into 
the  lungs.  When,  on  the  other  hand,  a  forced  expiration 
is  made  with  closed  glottis,  each  pressure  increases ;  hence, 
the  mtra-pulmonary  vessels  are  strongly  compressed,  and 
the  blood  is  thus  driven  out  of  the  lungs. 

Were  variations  in  the  intra-pulmonary  atmospheric 
pressure  the  sole  cause  of  the  variations  in  the  calibre 
of  the  intra-pulmonary  vessels,  it  would  follow  that  the 
lungs  could  Ije  made  to  contain  more  blood  when  con- 
tracted in  full  expiration  than  when  expanded  in  complete 
inspiration  :  all  that  would  be  necessary  would  be  to  inspire 
forciljly  with  closed  glottis  in  the  former  case,  and  similarly 
to  expire  in  the  latter  ;  the  contracted  lung  would  then 
contain  the  maximum  supply  of  blood,  and  the  expanded 
lung  the  minimum.* 

*  Seeing  that  the  inspiratory  muscles  can  act  to  greatest  advantage 
at  full  inspiration,  the  lungs,  on  the  above  assumption,  should  contain 
less  blood  if  a  forcible  expiration  with  closed  glottis  be  made  at  the  end 


INFLUENCE    ON   THE    CIRCULATION    OF   THE    BLOOD    85 

But  such  is  not  actually  the  case,  for  though  the  mtra- 
pulmonary  pressure  may  be  diminished  in  the  contracted 
lungs,  the  circumvascular  tissue  pressure  is  necessarily 
increased.  On  the  other  hand,  while  the  intra-pulmonary 
pressure  may  be  greatly  increased  in  the  expanded  lungs, 
the  circumvascular  tissue  pressure  is  necessarily  greatly 
diminished.  It  should  be  mentioned,  in  this  connection, 
that  the  breath  can  be  held  twice  as  long  when  the  lungs 
are  expanded  in  full  inspiration  as  when  contracted  in 
full  expiration,  and  this,  no  matter  how  we  modify  the  intra- 
pulmonary  atmospheric  pressure.  No  doubt  this  difference 
is  largely,  possibly  solely,  due  to  the  larger  quantity  of 
intra-pulmonary  air  in  the  one  case  than  in  the  other ; 
but  it  at  least  suggests  that  it  may  also  be  partly  due  to 
the  fact  that  the  circumvascular  tissue  pressure  is  negative 
in  the  one  case  and  positive  in  the  other,  the  former  favour- 
ing and  the  latter  retarding  the  pulmonary  flow. 

In  comparing  the  time  during  which  the  breath  can  be 
held  when  the  lungs  are  fully  expanded  by  inspiration  with 
the  time  during  which  it  can  be  held  when  they  are  fully 
contracted  by  expiration,  it  is  well  first  to  induce  apnoea  by 
breathing  rapidly  and  deeply  for,  say,  fifteen  seconds.  I 
find  that  if  I  then  hold  my  breath  in  full  expiration,  nearly 
a  minute  elapses  before  dyspncea  becomes  urgent ;  and, 
curiously  enough,  the  period  remains  much  the  same 
whether,  while  thus  holding  the  breath,  I  forcibly  inspire, 
or  expire  with  closed  glottis,  or  do  neither.  On  the  other 
hand,  if,  after  similarly  inducing  apncea,  I  hold  my  breath 
in  full  inspiration,  I  can  go  two  and  a  quarter  minutes 

of  a  full  inspiration  than  at  the  end  of  a  full  expiration.  Contrari- 
wise, the  expiratory  position  being  the  most  favourable  for  the  action 
of  the  inspiratory  muscles,  the  lungs  should  contain  more  blood  if  a 
forcible  inspiration  be  made  at  the  end  of  complete  expiration  than  at 
the  end  of  complete  inspiration. 


86  RESPIRATORY   EXERCISES 

before  there  is  an  urgent  desire  to  breathe.  And  here 
again,  the  pressure  to  which  the  intra-pulmonary  vessels 
are  subjected  by  forcibly  inspiring,  or  expiring  with  closed 
glottis,  makes  no  appreciable  difference  in  the  time  during 
which  the  breath  can  be  held. 

The  effect  of  the  inspiratory  expansion  of  the  intra-pul- 
monary vessels  is  to  lessen  the  resistance  which  they  oppose 
to  the  blood-flow,  and  consequently  to  increase  the  rate  of 
flow  through  the  pulmonary  circuit,  thereby  increasing  the 
output  from  the  right  heart  and  the  out-flow  from  the  lungs. 
As  against  the  increased  rate  of  flow  thus  resulting  we 
must  set  the  diminution  in  its  rate  brought  about  by  the 
widening  of  the  pulmonary  bed,^  and  a  further  circum- 
stance has  to  be  considered  in  this  connection :  not  only 
does  an  increase  in  vascular  calibre  tend,  by  the  widening  of 
the  bed,  to  diminish  the  rate  of  flow,  but  the  very  jJrocess  of 
vascular  dilatatioi  itself  tends  in  the  same  direction:  for  as 
the  vessels  open  out,  the  extra  vascular  space  thus  created 
has  to  be  filled  with  blood,  and  this  process  of  filling 
detracts  from  the  forward  movement  of  the  blood.  By  so 
much  as  the  vessels  open  out  and,  as  it  were,  su-allow  uj) 
the  blood,  by  so  much  is  the  pulmonary  output  diminished; 
and  it  is  conceivable  that  the  vascular  dilatation  might  be 
so  rapid  as  temporarily  to  check  the  pulmonary  outflow 
altogether — nay,  actually  to  suck  blood  from  the  left  heart 
into  the  lungs.  How  markedly  this  swallowing-up  process 
detracts  from  the  forward  flow  may  be  shown  by  taking  a 

*  Tlie  influence  of  pulmonary  expansion  on  the  pulmonary  '  bed ' 
will  be  most  marked  where  the  bed  is  widest,  i.e.,  in  the  neighbourhood 
of  the  arterioles,  capillaries,  and  venules,  and  consequently  its  effect 
on  rate  of  flow  will  also  be  most  marked  here.  The  widening  of  the 
bed  in  this  region  must  operate  very  decidedly  in  the  direction  of 
diminishing  the  rate  of  flow,  and  it  should  be  noticed  that  an  actual 
diminution  in  the  rate  of  flow  here  is  compatible  witli  an  increased 
pulmonary  output. 


TNFLUKNCK    OX    TUB    CIRCL-LATIOX    OF   THE    BLOOD    87 

very  rapid  and  deep  inspiration  after  a  forced  expiration 
with  closed  glottis,  when  the  sudden  change  in  the  calibre 
of  the  pulmonary  vessels  from  the  minimum  to  the  maximum 
diminishes  the  pulmonary  output  to  such  an  extent  as  to 
cause  the  individual  to  grow  pale  and  faint,  and  even  destroy 
all  trace  of  the  radial  pulse.  This  is  especially  the  case  in 
those  with  low  tension.  The  exact  converse  of  this  occurs 
during  effort,  as  in  coughing  or  lifting  a  heavy  weight.  A 
deep  inspiration  is  first  taken,  and  then  a  powerful  expira- 
tion with  partly  or  completely  closed  glottis.  In  this  way 
the  calibre  of  the  pulmonary  vessels  is  suddenly  changed 
from  a  minimum  to  a  maximum,  and  as  a  result  the  pul- 
monary blood  tends  to  be  driven  in  both  directions,  i.e., 
backwards  towards  the  right  heart,  and  forwards  into  the 
left  heart.  It  is  not  able  to  regurgitate  into  the  right  heart 
owing  to  the  pulmonary  valves,  but  although  checked  in 
this  direction,  it  is  doubtful  whether  much  can  escape  from 
the  right  heart  during  a  violent  effort.  On  the  other  hand, 
the  way  into  the  left  heart  being  open,  a  large  quantity  of 
blood  is  expressed  into  it.  In  this  connection  it  must  be 
borne  in  mind  that  the  venous  portion  of  the  pulmonary 
circuit  is  much  more  compressible  than  the  arterial  portion, 
owing  to  its  comparatively  low  tension.  The  effect,  there- 
fore, of  a  sudden  effort  is  to  squeeze  a  large  quantity  of 
blood  into  the  left  heart,  and  thus  to  increase  the  aortic 
input.*  It  is  in  this  way  we  can  explain  a  phenomenon  I 
have  frequently  observed,  viz.,  a  swelling  up  of  the  systemic 
arteries — the  temporals,  for  instance — during  cough.  Even 
more  effective  in  this  respect  is  a  sudden  effort  with  com- 

*  It  is  true  that  the  extra-puhuonary  portion  of  the  puhiionary  veins 
and  the  left  auricle  are  subject  to  great  pressure  during  effort,  and  this 
must  operate  in  the  direction  of  diminishing  the  input  into  the  left 
ventricle  ;  but  it  must  be  remembered  that  the  blood  pressure  in  all  of 
them  must  also  rise  very  considerably,  and  that  this  heightened  pressure 
\vill  diminish  their  compressibility. 


88  RESPIRATORY    EXERCISES 

pletely  closed  glottis.  It  is  probably  for  this  reason  that 
straining  at  stool  and  similar  efforts  are  so  liable  to  cause 
rupture  of  arterial  aneurysms,  whether  of  the  small  miliary 
aneurysms  of  the  cerebral  vessels  or  of  the  large  aneurysms 
situated  on  the  great  bloodvessels.  Another  factor  tending 
to  send  up  arterial  blood  pressure  in  these  cases  is  the 
powerful  contraction  of  the  abdominal  muscles,  and  the 
consequent  compression  of  the  abdominal  vessels.  As  I 
elsewhere  point  out,  compression  of  the  belly  may  in- 
crease the  work  of  the  heart  30  per  cent,  by  squeezing  blood 
from  the  splanchnic  area  into  other  parts  of  the  vascular 
system.  During  effort  such  compression  is  probably  not 
able  materially  to  increase  the  input  into  the  right  heart 
owing  to  the  increase  of  intra-thoracic  pressure,  but  it  tends, 
nevertheless,  to  send  up  the  systemic  arterial  pressure  by 
increasing  the  peripheral  resistance  in  the  splanchnic  area. 

Michael  Foster*  writes  as  though  the  swallowing-up  pro- 
cess above  referred  to  takes  place  during  the  beginning  of 
inspiration  only,  but  it  is  manifest  that  it  must  last  during 
its  entire  period.  It  is  quite  possible,  however,  that  it  is 
greatest  at  the  beginning  of  inspiration,  and  that  in  this 
way  it  may  cause  a  delay  in  the  increased  output  brought 
about  by  the  diminished  pulmonary  resistance.  It  will  be 
observed  that,  while  it  tends  to  diminish  the  pulmonary 
output,  it  increases  the  input  by  actually  sucking  blood  out 
of  the  right  heart. 

2.  In  order  to  understand  the  influence  of  the  second 
factor,  the  facts  enunciated  in  Chapter  I.  must  be  borne  in 
mind.  It  is  there  pointed  out  that  the  heart  and  its  great 
bloodvessels  are,  under  ordinary  circumstances,  subjected 
to  pulmonary  suction,  this  suction  operating  even  at  the 
end  of  an  ordinary  expiration,  and  increasing  with  every 
inspiration.  It  constitutes  an  important  aid  to  the  circula- 
tion, sucking,  as  it  does,  l^lood  from  the  veins  of  the  neck 
*  '  Text-Book  of  Physiology,'  sixth  edition,  Part  11.,  p.  650. 


INFLUENCE    ON    THE    CIRCULATION    OF   THE   BLOOD    89 

and  upper  extremities  (on  which  the  pressure  is  at  least 
equal  to  the  ordinary  atmospheric  pressure)  into  the 
innominates  and  superior  cava,  and  from  the  abdominal 
veins  (on  which  the  pressure  is  likewise  positive)  into  the 
inferior  cava  ;  also  from  the  lungs  into  the  pulmonary 
veins.  Its  influence  on  the  heart  also  favours  the  circula- 
tion, inasmuch  as  it  facilitates  diastole  (the  degree  of  which 
largely  determines  the  amount  of  blood  Howing  into  the 
heart)  much  more  than  it  retards  systole.  Ventricular 
systole  must,  indeed,  be  very  little  influenced  by  it. 

The  effects  just  considered  are  greatly  increased  when 
inspiration  is  made  with  closed  glottis,  by  which  means 
suction  may  be  raised  to  — 100  mm.  Hg.  Under  these  cir- 
cumstances the  blood  is  sucked  with  considerable  force  into 
the  cavffi  and  right  heart,  and  from  the  pulmonary  veins 
into  the  left  heart.  On  the  other  hand,  such  powerful  suc- 
tion must  hamper  systole,  especially  auricular  systole  ;  but 
any  retardation  of  the  circulation  thus  resulting  is  over- 
balanced by  the  acceleration  of  diastole. 

Pulmonary  suction  ceases  with  a  full  expiration,  the 
pressure  on  the  heart  and  great  bloodvessels  then  becoming 
positive,  and  if  a  violent  expiration  is  made  with  closed  glottis, 
it  may  amount  to  100  mm.  Hg  or  more.  Such  a  pressure 
on  the  cavfB  and  pulmonary  veins  must  tend  to  obliterate 
them,  and  to  render  cardiac  diastole  (notably  of  the  auricles) 
very  difficult.  The  heart  and  great  bloodvessels  may,  indeed, 
be  so  firmly  compressed  in  this  way  as  almost  to  check  the 
circulation  altogether  for  a  time. 

Since  pulmonary  suction  constitutes  an  important  aid 
to  the  circulation,  it  follows  that  any  loss  of  pulmonary 
elasticity  is  detrimental  to  the  same.  This  is  one  of  the 
reasons  why  in  emphysema  the  blood  tends  to  accumulate 
in  the  systemic  veins. 

3.  With    every   descent   of    the   diaphragm   the    intra- 


90  RESPIRATORY    EXERCISES 

abdominal  vessels  are  compressed.  The  tense  arteries  are 
very  little  influenced  by  this  pressure,  but  the  flaccid  veins 
yield  to  it,  blood  being  squeezed  out  of  them  into  the  right 
heart,  for  though  the  intra-abdominal  veins  are  not  pro- 
vided with  valves,  those  of  the  lower  extremities  have  them, 
and  consequently  the  blood  cannot  regurgitate  from  the 
iliacs  into  them.  Hence,  as  Marey  observes,  the  pressures 
in  the  intra-thoracic  and  intra-abdominal  veins  run  in 
opposite  directions,  the  former  falling  during  inspiration, 
and  the  latter  rising,  and  vice  versa.  (I  refer  to  diaphrag- 
matic inspiration.)  In  the  portal  veins  the  pressure  may 
rise  several  millimetres  of  mercury.* 

The  effect  of  diaphragmatic  inspiration  in  increasing 
intra-abdominal  tension  and  thus  squeezing  blood  out  of 
the  intra-abdominal  veins  into  the  right  heart,  is  largely 
dependent  upon  the  condition  of  the  anterior  abdominal 
walls.  When  these  are  lax  and  flaccid,  tension  is  very  little 
increased,  even  by  extreme  contraction  of  the  diaphragm. 
On  the  other  hand,  when  the  abdominal  walls  are  strongly 
contracted  or  firmly  compressed,  as  by  a  belt,  or  by  flexing 
the  body  on  the  thighs,  forcible  contraction  of  the  diaphragm 
may  cause  considerable  augmentation  of  tension. 

It  should  be  observed,  however,  that  inspiration  does  not 
always  augment  intra-abdominal  tension ;  it  may  produce 
the  very  opposite  result.  Thus,  when  the  fullest  possible 
thoracic  breath  is  taken,  abdominal  tension  falls,  owing  to 
the  powerful  suction  of  the  lungs  upon  the  diaphragm  ;  and 
the  fall  l)ecomes  still  greater  if  the  breath  be  taken  with 
closed  glottis.  The  effect  of  this  diminished  tension  is  to 
draw  the  blood  from  the  lower  extremities  and  abdomino- 
pelvic  viscera  into  the  intra-abdominal  veins. t 

*  Marey  points  out  that  the  action  of  the  abdominal  muscles,  which 
(in  the  dog,  at  least)  tend  to  contract  during  expiration,  and  thus  to 
compress  the  intra-abdominal  veins,  introduces  a  disturbing  influence 
('  La  Circulation  du  Sang,'  Paris,  IBBl,  pp.  417,  529), 

t  For  a  practical  application  of  the  above  facts,  see  p.  151  ct  scq. 


INFLUENCE   ON    THE   CIRCULATION   OF   THE   BLOOD    91 

While  intra-abdominal  pressure  tends  to  fall  during 
ordinary  expiration,  it  increases  when  expiration  is  forced, 
especially  when  the  glottis  is  closed,  as  in  effort ;  but  the 
compression  of  the  intra-abdominal  veins  thus  resulting 
does  not  urge  the  blood  onward,  owing  to  the  concomitant 
increase  in  intra-thoraeic  pressure. 

It  will  probably  be  concluded  from  the  foregoing  obser- 
vations that  the  ordinary  respiratory  movements  favour  the 
circulation,  but  it  is  doubtful  whether  in  ordinary  breathing 
they  have  any  decided  effect.  While  the  rhythmic  descent 
of  the  diaphragm  aids  the  circulation,  it  is  doubtful 
whether  the  rhythmic  expansion  and  contraction  of  the 
lungs  have  the  same  result,  seeing  that  the  accelerating 
influence  of  expansion  is  neutralized  by  the  retarding 
influence  of  contraction.  We  have  seen  that  pulmonary 
suction  is  largely  dependent  upon  the  degree  to  which 
the  very  elastic  lungs  are  stretched.  During  inspiration 
the  elastic  tension  rises  to  a  given  point,  and  during  ex- 
piration it  falls  again  to  the  original  point.  Hence  the 
mean  tension  is  the  same  during  both  inspiration  and  ex- 
piration, and  so  far  as  pulmonary  suction  is  dependent 
upon  pulmonary  tension,  it  is  the  same  during  both  inspira- 
tion and  expiration.  Pulmonary  suction  is,  however,  also 
influenced  by  the  intra-pulmonary  air  pressure.  This  latter 
falls  during  inspiration,  and  in  so  doing  increases  the  suc- 
tion upon  the  heart  and  extra-pulmonary  bloodvessels, 
while  it  also  causes  an  expansion  of  the  intra-pulmonary 
vessels ;  but  the  accelerating  influence  of  this  diminished 
intra-pulmonary  pressure  is  counteracted  by  the  expiratory 
increase  of  intra-pulmonary  pressure,  which  not  only 
diminishes  the  suction  upon  the  heart  and  great  blood- 
vessels, but  likewise  the  calibre  of  the  intra-pulmonary 
vessels. 


92  RESPIRATORY   tXERCISES 

It  would  thus  appear  that  if  msph-ation  and  expiration 
are  of  equal  duration  (as  under  ordinary  circumstances  they 
practically  are),  the  respiratory  expansion  and  contraction 
of  the  lungs  will  not  aid  the  circulation.  How,  then,  are 
we  to  account  for  the  fact  that  the  circulation  is  impeded 
when  the  breath  is  held?  Marey  has  shown,  by  taking 
tracings  of  the  right  ventricle  under  these  conditions,  that 
its  beats  become  slower  and  that  it  manifests  an  increasing 
difficulty  in  emptying  itself,  the  amount  of  residual  blood 
increasing  with  every  beat.  This  latter  fact  is  further 
attested  by  the  increase  of  dulness  to  the  right  of  the 
sternum,  and  by  the  distension  of  the  veins  of  the  head  and 
neck.  These  phenomena  certainly  suggest  that  by  holding 
the  breath  we  remove  a  something  which  facilitates  pul- 
monary circulation.  It  must,  however,  be  remembered 
that  when  an  individual  is  asked  to  hold  his  breath,  he 
closes  the  glottis,  and  makes  an  unconscious  expiratory 
effort,  thus  increasing  the  intra-pulmonary  pressure ;  also 
that  holding  the  breath  checks  the  respiratory  blood-change, 
the  pulmonary  circulation  being  hindered  in  consequence.* 

But  while  the  rhythmic  movements  of  the  lungs  do  not 
under  ordinary  circumstances  aid  the  circulation,  there  are 
certain  positions  of  the  chest  and  certain  modes  of  breathing 
which  are  favourable  to  it,  and  it  behoves  us  thoroughly  to 
understand  what  these  are.  Since  pulmonary  suction  aids 
the  blood-flow,  it  follows  that  increase,  in  mean  puhnonary 
suction  Kill  favour  the  circulation.  Such  an  increase  may 
be  effected  by  inflating  the  chest  to  the  utmost  with  every 
inspiration,  and  limiting  the  expiratory  range.  In  this 
way  the  transference  of  blood  from  the  veins  to  the  arteries 
is  facilitated.  It  may  further  be  aided  hy  ijrolowjiiKj  the 
inspiratory  periods  and  shortening  the  expiratory,  for  by  this 
means  the  period  of  lessened  becomes  longer  than  the  period 
*  See  pp.  142-144. 


INFLUENCE    OX    THE    CIRCULATION    OF   THE    BLOOD    93 

of  heightened  intra-iDulmonary  tension ;  i.e.,  the  period 
of  acceleration  becomes  longer  than  that  of  retardation. 
The  mode  of  breathing,  therefore,  most  favourable  to  the 
circulation  is  to  take  slow  full  inspirations  (preferably 
through  the  nose},  followed  by  short  and  somewhat  shallow 
expirations  (preferably  through  the  mouth).  This  is,  indeed, 
the  method  often  instinctively  resorted  to  when  there  is  need 
of  facilitating  the  transit  of  blood  from  the  cavfe  to  the 
aorta.  In  running,  for  instance,  the  blood  is  diverted  in 
large  quantities  from  the  splanchnic  area  to  the  muscles, 
whence  it  is  pumped  with  great  rapidity  into  the  right 
heart,  which  has  some  difficulty  in  disburdening  itself  of  this 
large  access  of  blood.  Now,  the  mean  size  of  the  chest  is 
manifestly  increased  in  running,  full  inspirations  being 
taken,  while  expirations  stop  short  of  their  ordinary  limit. 
Further,  as  breathlessness  becomes  marked  the  expirations 
get  distinctly  shorter  than  the  inspirations.  A  ready  way 
of  demonstrating  this  disproportion  is  to  notice  how  many 
paces  can  be  taken  during  the  one  and  the  other  respectively. 
Legrange  found  that  when  breathlessness  became  decided  he 
took  thirteen  paces  during  each  inspiration,  and  only  five 
during  an  expiration.  When  the  breathlessness  has  become 
pronounced  it  will  be  found  quite  impossible  to  make  the 
two  acts  equal  :  inspiration  may  be  voluntarily  prolonged, 
but  not  expiration,  which  is  always  cut  suddenly  short  by 
the  imperious  demand  to  inspire.  Hence  it  is  that  expira- 
tion does  not  proceed  to  the  ordinary  limit,  the  mean  size 
of  the  chest  being  in  consequence  increased  and  the  circula- 
tion through  the  lungs  thereby  facilitated. 

Legrange,  who  was,  I  believe,  the  first  to  point  out  the 
alteration  in  rhythm  just  referred  to,  explains  it,  as  I  have 
done,  by  reference  to  the  favouring  influence  on  the  circula- 
tion of  deep  inspirations,  and  the  retarding  influence  of 
deep  expirations,  the  individual  in  consequence  instinctively 


94  RESPIRATORY   EXERCISES 

prolonging  the  one  and  shortening  the  other.  The  altered 
rhythm  cannot,  he  argues,  be  due  to  mechanical  causes, 
seeing  that  it  occurs  in  exercises  of  the  arms  as  well  as  of 
the  legs,  and  that  it  lasts  for  some  time  after  the  exercise 
"which  has  induced  it. 

In  all  forms  of  dyspnoea  there  is  the  same  difficulty  in 
getting  the  blood  through  the  lungs  and  the  same  tendency 
to  take  full  inspirations  and  short  incomplete  expirations. 
Hence,  in  dyspncea  we  find  the  inspiratory  muscles  more 
active  than  the  expiratory. 

Influence  of  the  Respiratory  Movements  on  Arterial  and 
Venous  Tension. — We  are  now  in  a  position  to  consider  this 
influence.* 

Inspiration  favours  the  flow  of  blood  into  the  cavae  and 
right  heart,  from  the  latter  into  the  lungs,  and  from  the 
lungs  into  the  left  heart.  In  short,  it  favours  the  trans- 
ference of  blood  from  the  systemic  veins  into  the  systemic 
arteries,  and  its  effect  is  most  marked  when  the  glottis 
is  closed.  Hence,  inspiration  causes  a  fall  of  venous 
blood  pressure,  especially  in  the  superior  cava  (the  cranial 
fontanelles  and  veins  of  the  neck  collapsing), -f-  and  a  rise 
of  pressure  in  the  systemic  arteries.  |  Expiration,  on  the 
other  hand,  impedes  the  flow  of  blood  from  the  veins  into 

•*•  The  influence  of  the  respiratory  movements  on  arterial  tension  has 
been  skilfully  treated  of  by  De  Jager.  See  Jour.  Pliys.,  vol.  vii.,  No.  2, 
p.  130;  also  Pltiger's  Archiv.,  ]3cl.  20,  27,  33,  and  36,  and  Arch.  Neerl. 
T.,  19  and  20,  which  contain  copious  references  to  the  literature  of  the 
subject. 

j"  The  effect  of  inspiration  upon  the  pressure  in  the  inferior  cava 
varies  according  to  circumstances :  a  deep  abdominal  breath  increases 
it ;  a  deep  costal  breath  diminishes  it. 

X  Inspiration,  by  increasing  the  amount  of  blood  in  the  lungs,  tends 
to  cause  a  fall  in  arterial  as  well  as  in  venous  pressure  ;  but  by  diminish- 
ing ])ulmonary  resistance  it  tends  to  cause  a  rise  in  arterial  pressure, 
the  latter  effect  preponderating.  See  De  Jager,  Jour.  P/iys.,  vol.  vii., 
No.  2,  pp.  196-198,  206-208. 


INFLUENCE   ON   THE   CIRCULATION   OF   THE   BLOOD    95 

the  arteries,  its  effect  being  greatest  when  forced  and  with 
closed  glottis.  Hence,  venous  blood  pressure  rises  during 
expiration,  the  fontanelles  and  cervical  veins  swelling  up, 
while  arterial  blood  pressure  falls. 

These  respiratory  alternations  in  arterial  blood  pressure 
do  not  exactly  synchronize  with  the  respiratory  movements. 
Thus,  the  expiratory  fall  continues  into  the  beginning  of 
inspiration,  possibly  because  the  first  effect  of  inspiration  is 
to  diminish  the  pulmonary  output ;  indeed,  this  inspiratory 
fall  may,  as  we  have  seen,  be  very  marked  if  a  deep  and 
rapid  inspiration  be  taken  after  a  forced  expiration  with 
closed  glottis.  On  the  other  hand,  the  inspiratory  rise 
continues  into  the  beginning  of  expiration,  the  first  effect 
of  which  is  to  augment  the  pulmonary  output  by  expressing 
blood  into  the  left  heart.  If  expiration  be  made  powerfully 
with  partly  or  completely  closed  glottis,  this  expiratory  rise 
may,  as  already  observed,  be  decided.  It  is,  however,  only 
momentary,  the  final  effect  of  a  protracted  expiration  of 
this  kind  being  a  considerable  lowering  of  arterial  and  a 
corresponding  rise  of  venous  pressure,  for  not  only  is  the 
circulation  through  the  lungs  and  great  veins  entering 
the  heart  impeded,  but  the  action  of  the  heart  itself. 
Eduard  Weber  pointed  out  that  even  a  moderate  expiratory 
effort,  while  the  mouth  and  nostrils  are  closed,  renders  the 
pulse  slow  and  small  and  the  heart-sounds  indistinct,  more 
forcible  expiration  causing  the  radial  pulse  to  disappear 
completely,  an  efl'ect  which  Oertel  attributes  to  the  '  com- 
pression of  the  subclavian  artery  by  the  strongly  raised 
upper  ribs.'* 

"Whatever  augments  intra-thoracic  pressure,  such  as  cough- 
mg,  vomiting,  straining  at  stool,  lifting  a  heavy  weight  with 
closed  glottis,  has  similar  effects.     These  different  kmds  of 

*  Von  Zeimssen's  'Handbook  of  General  Therapeutics,'  vol.  iii., 
p.  468. 


96  EESPIRATORY    EXERCISES 

effort  and  their  influence  on  the  circulation  are  more  par- 
ticularly considered  in  Chapter  XVI. 

It  has  been  shown  by  Leonard  Hill  and  Barnard  that 
external  compression  of  the  thorax  affects  the  circulation  in 
the  same  way  as  expiration  with  closed  glottis,  and  they  insist 
that  whatever  raises  intra-pulmonary  air  pressure  causes  a 
fall  in  arterial  and  a  rise  in  venous  pressure,  '  the  diastolic 
filling  of  the  heart  and  the  passage  of  blood  through  the 
lungs  being  thereby  impeded,'  so  that  the  effect  on  the 
circulation  is  the  same  as  that  produced  b}^  obstructive 
lung  disease  and  cardiac  failure. 

Tight-lacing  causes  external  compression  of  the  thorax, 
and  therefore  impedes  the  pulmonary  circulation,  damming 
it  back  upon  the  systemic  veins. 

These  two  physiologists  have  also  brought  out  a  point  in 
connection  with  the  radial  pulse  which  has  hitherto  been 
strangely  overlooked,  namely,  that  the  radial  artery  has 
two  venae  comites,  and  that  the  quality  of  the  radial  pulse 
is  affected  by  the  degree  to  which  these  two  veins  are  dis- 
tended. When  examining  the  radial  pulse,  we  feel  in  fact 
three  vessels,  and  these  we  may  speak  of  as  the  radial  band. 

Now,  Blake  observed  that  forced  expiration  increased  the 
size  of  the  radial  pulse.  This  was  proved  by  careful  obser- 
vations with  the  arteriometer,  and  by  the  fact  that  the  base 
line  of  the  sphygmographic  curve  rises  with  forced  expira- 
tion. How  to  reconcile  this  fact  with  the  fact  that  increased 
intra-thoracic  pressure  lowers  arterial  tension  was  a  problem 
which  Blake  presented  to  Leonard  Hill  for  solution.  By 
a  series  of  ingenious  experiments  Hill  and  Barnard  have 
conclusively  proved  that  the  increase  in  the  size  of  the 
radial  pulse  produced  by  forced  expiration  is  due  to  disten- 
sion of  the  \enni  comites,*  and  that  anything  which  causes 

*  Such  an  expiration  may,  as  we  have  seen,  produce  a  distension  of 
the  arteries,  but  this  is  momentary  only. 


INFLUENCE    ON    THE    CIRCULATION    OF  THE   BLOOD    1)7 

the  blood  to  be  damiiied  back  upon  the  great  veins  pro- 
duces the  same  effect.  They  msist  that  it  is  impossible  to 
differentiate  between  the  venous  and  arterial  aspects  of  the 
radial  pulse,  and  that  the  fulness  of  the  ven<e  comites  gives 
a  distinct  character  to  the  radial  pulse,  whether  tested  by 
the  finger  or  the  sphygmograph.  For  this  reason  they 
hold  that  the  quality  of  '  fulness  between  the  beats  '  does 
not  necessarily  signify  high  arterial  tension.  Sir  William 
Broadbent  attaches  great  importance  to  this  phenomenon  as 
evidence  of  high  arterial  tension,  but  by  '  fulness  between 
the  beats  '  he  evidently  means  a  sense  of  fulness  irJien  a  fair 
decree  of  pressure  is  applied  to  the  pulse.  Now,  a  vein 
when  under  a  high  venous  pressure  is  quite  easily  compres- 
sible, and  hence  the  physician  would  be  very  unlikely  to 
mistake  overdistension  of  the  radial  vena3  comites  for  high 
arterial  tension. 

Influence  of  the  Respiratory  Movements  on  the  Pulse-Rate. — 
In  man,  the  dog,  and  certain  other  animals,  the  rate  of  the 
pulse  increases  during  inspiration,  diminishing  again  during 
expiration.  This  phenomenon  is  due  to  cardiac  inhibition 
taking  place  with  every  expiration,  for  if  in  the  dog  the 
vagi  be  cut,  the  respiratory  variations  in  pulse-rate  cease. 
The  modifications  in  pulse-tension,  however,  continue,  and 
this  shows  that  these  latter  are  not  dependent  upon  the 
rhythmic  alteration  in  rates. 

But  while  the  act  of  inspiration  quickens  the  pulse  and 
that  of  expiration  slows  it,  holding  the  breath  in  extreme 
inspiration  slows  the  pulse  while  holding  it  in  extreme 
expiration  quickens  it.  Thus,  the  following  results  were 
obtained  in  my  own  case  :  ' 

Ordinary  pulse  ...  ...  ...     ;j;3,  r)2,  50,  52,  53. 

With  chest  fixed  in  expiration  ...  ...     58,  .54,  56,  58,  58. 

With  chest  fixed  in  inspiration  ...  ...     52,  48,  51,  52,  5L 

7 


98  RESPIRATORY    EXERCISES 

Dr.  Edward  Blake,  who  directed  my  attention  to  these 
effects,  has  obtained  much  wider  divergences  than  I  give. 
Thus,  in  one  of  his  observations  a  pulse  of  80  was  reduced 
to  64  by  holding  the  breath  in  extreme  inspiration,  while  in 
another  case  a  pulse  of  65  was  increased  to  76  by  holding 
it  in  the  expiratory  position.* 


The  Effects  of  the  Respiratory  Movements  on  the  Cerebral 
Circulation. — These  effects  are  so  important  from  the  thera- 
peutical point  of  view  that  it  is  necessary  to  describe  them, 
if  only  briefly. 

The  skull  after  infancy  being  a  closed  cavity,  the  volume 
of  its  contents  must  always  remain  the  same.  Now,  the 
brain-substance  is  incompressible,  and  the  researches  of 
George  Elder t  would  appear  to  prove  that  the  quantity  of 
cerebro-spinal  fluid  within  the  skull  remains  constant.  It 
therefore  follows  that  the  quantity  of  blood  within  the 
closed  cranium  always  remains  the  same  (Munro-Kellie 
doctrine).  This  does  not,  however,  imply  that  the  calibre 
of  the  intra-cranial  vessels  can  never  alter,  for  the  brain- 
matter,  though  incompressible,  must  not  be  regarded  as 
a  rigid  substance,  but  diffluent  rather,  and  capable  of 
altering  in  position  in  response  to  alteration  in  the  calibre 
of  the  cerebral  vessels.  With  every  beat  of  the  heart  the 
cerebral  arteries  dilate,  thus  displacing  the  brain-substance 
and  causing  a  corresponding  contraction  of  the  cerebral 
veins ;  similarly,  as  the  arteries  recoil,  the  brain-substance 
closes  in  about  them,  thus  allowing  the  veins  to  dilate ; 
there  is,  in  fact,  an  alternate  pulsation  of  the  arteries  and 
veins.     Elder  concludes  that  the  respiratory  movements  are 

*  The  Medical  Times  and  Hospital  Gazette,  March  and  April,  1897. 
■f-  'The  Intra-cranial  Circulation  in  some  of  its  Aspects':  Brit.  Med. 
Jour.,  1897,  vol.  ii.,  p.  1414. 


INFLUENCE   ON    THE    CIRCULATION    OF   THE    BLOOD    99 

likewise  capable  of  modifying  the  calibre  of  the  cerebral 
vessels.  The  effect  of  inspiration  is  to  cause  a  depression, 
and  of  expiration  to  cause  a  bulging,  of  the  anterior 
fontanelle.  There  can  be  no  doubt  that  the  former  is  due 
to  a  collapse  of  the  cerebral  veins  (not  the  sinuses,  which  are 
said  to  be  incompressible)  owing  to  the  suction  of  the 
thorax,  and  the  latter  to  a  distension  of  them  from  the 
effect  of  expiration  in  hindering  the  return  of  venous  blood. 
Now,  Elder  is  inclined  to  believe  that  the  same  thing  occurs 
in  the  closed  skull,  but  seeing  that  he  also  believes  the  volume 
of  intra-cranial  blood  always  to  remain  the  same,  he  is 
compelled  to  assume  that  the  supposed  inspiratory  venous 
collapse  is  accompanied  by  a  corresponding  arterial  dilata- 
tion, and  the  expiratory  venous  distension  by  a  correspond- 
ing arterial  collapse,  the  modification  in  arterial  calibre 
being  effected  through  modifications  in  the  pressure  of  the 
brain-substance,  this  latter  being  always  the  same  as  that 
of  the  intra-cranial  venous  pressure.  I  cannot  accept 
Elder's  conclusion.  In  order  that  the  supposed  inspiratory 
venous  distension  should  cause  arterial  contraction,  the 
venous  pressure  would  have  to  be  greater  than  the  arterial 
pressure,  which  it  never  is.  Assuming,  therefore,  that  the 
quantity  of  intra-cranial  blood  is  constant,  we  must  con- 
clude that  the  effect  of  inspiration  on  the  cerebral  circula- 
tion is  to  hurry  on  the  venous  flow,  without  causing  these 
vessels  to  diminish  in  calibre,  and  as  they  do  not  alter  in 
calibre,  it  is  clear  that  the  suction  action  must  extend  along 
the  entire  cerebral  circuit,  accelerating  the  arterial  and 
capillary  as  well  as  the  venous  circulation,  the  cerebral 
flow  being  further  favoured  by  the  inspiratory  rise  of 
arterial  pressure.  Hence  with  every  inspiration  blood  is 
drawn  out  of,  and  pumped  with  increased  force  into,  the 
brain.     By  taking  deep  inspirations,  followed  by  short  and 

7—2 


100  RESPIRATORY    EXERCISES 

shallow  expirations,  we  can  so  quicken  the  cerebral  circula- 
tion as  to  induce  temporary  unconsciousness.  When  we 
reflect  that  the  intra-cranial  lymph-flow  is  at  the  same  time 
quickened,  it  is  manifest  that  we  have  thus  at  our  com- 
mand a  means  of  profoundly  modifying  the  cerebral  pro- 
cesses. 


CHAPTEE  XIY. 

THE  INFLUENCE  UPON  THE  CIRCULATION.  ETC.,  OF 
MODIFICATIONS  IN  THE  DENSITY  OF  THE  OUTER 
AIR. 

There  are  various  ways  of  modifying  the  pressure  of  the 
external  atmosphere,  and  since  these  have  a  profound 
influence  upon  the  circulation,  they  must  be  considered 
here.  Thus,  the  entire  body  can  be  immersed  in  a  con- 
densed or  a  rarefied  atmosphere  by  condensing  or  rarefying 
the  air  in  an  air-tight  chamber.  It  is  further  possible,  by 
means  of  suitable  apparatus,  to  modify  intra-pulmonary 
tension  without  altering  the  general  atmospheric  pressure. 
Thus,  the  patient  can  be  made  to — 

(a)  Inspire  into  condensed  air. 

(h)  Expire  into  condensed  air. 

(c)  Inspire  rarefied  air. 

(d)  Expire  into  rarefied  air. 

These  various  methods  are  practically  unknown  m  this 
country,  but  they  have  been  carefully  studied  and  largely 
employed  on  the  Continent.  The  reader  will  find  a  detailed 
account  of  them  m  ^Yaldenburg's*  and  Oerters+  works.  I 
shall  therefore  only  very  briefly  touch  upon  the  subject  here. 

-  '  Die  Pneumatische  Behandlung  der  Respirations-  u.  Circulatioiis- 
Ki'aiikheiten.' 

t  "Van  Ziemssen's  '  Handbook  of  General  Therapeutics,'  vol.  viii. 
Translated  by  J.  Burnoy  Yeo,  M.D.,  F.R.C.P.  ;  London,  1885. 


102  RESPIRATORY   EXERCISES 

The  Effects  of  immersing  the  Body  in  Compressed  Air. — The 

blood  is  expressed  from  the  kmgs  and  the  surface  of  the 
body,  and  driven  into  the  abdomino-pelvic  viscera.  Hence, 
the  secretions  of  the  kings  and  the  skin  are  diminished, 
while  those  of  the  stomach,  intestines,  kidneys,  and  uterus 
are  increased.  The  heart  and  great  bloodvessels  are  com- 
pressed, the  extent  of  cardiac  contractions  diminished; 
the  pulse  gets  slower,  and  its  absolute  tension  higher  than 
usual.  The  respiratory  movements  are  deeper,  slower,  and 
more  easily  performed.  Vital  capacity  increases  ;  there  is 
augmentation  of  thoracic  capacity,  chiefly,  it  would  seem, 
from  compression  of  the  diaphragm.  Absorption  of  0  and 
elimination  of  CO2  are  mcreased.  This  shows  that  increased 
metabolism  occurs,  a  fact  which  harmonizes  with  the  great 
capacity  for  sustained  muscle-effort  among  workers  in  com- 
pressed air,  and  with  the  rapid  loss  in  weight  which  they 
undergo. 

By  means  of  a  contrivance  in  the  wall  of  the  compressed- 
air  chamber,  the  patient  is  enabled  to  expire  into  the  ex- 
ternal atmosphere,  the  expiratory  range  being  thus  increased 
and  the  quantity  of  residual  air  diminished. 

The  Effects  of  Rarefied.  Air. — These  are  sought  for,  not 
by  means  of  the  rarefied-air  chamber,  but  by  residence  in 
mountainous  districts.  The  lungs  and  skin  become  hyper- 
semic,  and  their  secretions  correspondingly  augmented,  the 
reverse  being  the  case  with  the  abdomino-pelvic  organs. 
The  heart  beats  more  rapidly,  and  the  absolute  arterial 
pressure  is  lowered.  The  chest  expands,  the  respirations 
get  deeper  and  slower  ;  the  vital  capacity,  however, 
diminishes,  from  the  expansion,  it  is  thought,  of  the  in- 
testinal gases  and  consequent  elevation  of  the  diaphragm. 
The  absorption  of  0  and  the  elimination  of  COg  are 
diminished,  while  the  temperature  of  the  body  tends  to 
fall. 


THE    INFLUENCE    OF    INSPIRING    CONDENSED    AIR     103 

The  Effects  upon  the  Circulation  of  varying  the  Density  of  the 
Air  inspired  and  expired  into,  the  General  Atmospheric  Pres- 
sure remaining  the  same. — In  explaining  these  effects,  I 
shall  make  no  reference  to  the  influence  of  modifications  of 
intra-pulmonary  pressure  on  ventricular  systole  and  diastole. 
Inspiration  of  condensed  air  favours  systole  and  interferes 
with  diastole,  while  inspiration  of  rarefied  air  favours 
diastole  and  interferes  with  systole,  in  either  case  the 
favouring  influence  on  the  one  being  more  or  less  balanced 
by  its  interfering  influence  on  the  other. 

(a)  Inspiration  of  condensed  air  interferes  with  the  induc- 
tion of  the  negative  intra-pulmonary  pressure  during  in- 
spiration. There  may,  indeed,  be  a  brief  phase  of  negative 
pressure  at  the  very  beginning  of  inspiration,  especially  if 
sudden  ;  it  soon,  however,  becomes  positive,  and  at  the  end 
of  inspiration  is  practically  the  same  as  that  of  the  air  in 
the  apparatus  used.  The  effect  of  this  heightened  intra- 
pulmonary  pressure  is  much  the  same  as  that  produced 
by  effort.  The  pulmonary  vessels  are  compressed,  so  that 
the  lungs  become  pale  ;  the  auricles  and  the  great  veins 
entering  the  heart  are  also  compressed,  and  hence  the  cir- 
culation through  the  lungs  is  impeded,  the  blood  being 
dammed  back  upon  the  right  heart  and  systemic  veins, 
and,  indeed,  if  the  degree  of  condensation  be  sufficiently 
great,  it  may  actually  be  stopped.  If  now  expiration  be 
made  into  an  atmosphere  of  ordinary  density,  the  heightened 
intra-pulmonary  pressure  gradually  diminishes,  but  it  is 
not  until  towards  the  end  of  expiration,  when  the  con- 
densed air  has  freely  escaped,  that  the  pressure  in  the 
lungs  attams  its  normal  expiratory  level. 

It  will  thus  be  seen  that,  so  far  as  its  immediate  effects 
on  the  circulation  are  concerned,  no  good  purpose  can  be 
served  by  the  inspiration  of  condensed  air,  in  spite  of 
Waldenburg's  argument  to  the  contrary.     "Whatever  good 


104  RESPIRATORY    EXERCISES 

may  come  of  it  is  indirect,  and  traceable  to  the  larger 
volume  of  oxygen  thus  introduced,  and  to  the  influence  of 
condensed  air  in  opening  out  collapsed  vesicles. 

(b)  Expiration  into  compressed  air  has  a  similar,  but  even 
more  marked,  effect  on  the  circulation,  the  result  being 
strictly  comparable  to  that  of  effort,  or  to  what  happens  in 
Valsalva's  experiment.  The  increase  of  intra-pulmonary 
pressure  does  not  cease  with  the  beginning  of  inspiration, 
for  the  pulmonary  air  being  then  condensed,  the  normal 
degree  of  inspiratory  rarefaction  cannot  at  once  be  attained. 

(c)  Inspiration  of  rarefied  air  causes  the  inspiratory 
negative  pressure  to  become  still  more  negative,  and  thus 
increases  inspiratory  suction,  the  blood  flowing  more  abun- 
dantly into  the  right  heart,  and  from  the  right  heart  through 
the  lungs  into  the  left  heart,  for  which  reason  it  is 
especially  indicated  in  passive  engorgement  of  the  lungs 
and  systemic  veins.  Its  effect  does  not  end  with  inspira- 
tion, the  negative  pressure  not  being  effaced  until  expiration 
is  somewhat  advanced. 

(d)  Expiration  into  rarefied  air  may  be  employed  in 
similar  cases,  reducing  as  it  does  intra-pulmonary  tension 
during  expiration,  and  causing  it  to  remain  negative  even 
(at  the  end  of  a  deep  expiration,  when  under  ordinary 
circumstances  it  is  decidedly  positive.  Hence,  a  marked 
suction  action  is  established  during  expiration,  when 
normally  it  is  all  but  absent.  The  effect  continues  into 
inspiration,  the  initial  expansion  of  the  lungs  causing  the 
rarefied  air  to  become  still  more  rarefied ;  gradually,  how- 
ever, the  influx  of  air  at  the  ordinary  density  establishes  the 
normal  inspiratory  pressure. 

Excessive  rarefaction  of  the  air  breathed  does  not  favjour 
'the  flow  into  the  right  heart.  The  greater  the  rarefaction, 
•the  greater  is  pulmonary  suction,  and  when  this  has 
'become  sufficient  to  produce  an  extreme  degree  of  negative 


EXPIRATION    INTO    RAREFIED    AIR  105 

pressure  in  the  great  veins  of  the  neck  and  abdomen,  these 
became  flattened  by  the  atmospheric  pressure,  the  supply 
of  blood  to  the  right  heart  being  thus  diminished.  In 
engorged  right  heart,  whether  from  disease  of  the  lung  or 
left  heart,  such  curtailment  in  its  ])lood-supply  is  beneficial. 
In  such  cases,  however,  the  blood-pressure  in  the  large 
systemic  veins  is  considerable,  attaining,  it  may  be,  several 
millimetres  of  mercury,  and  it  is  not  easy  to  render  it 
negative. 

We  must  be  careful  not  to  produce  too  great  rarefaction 
of  the  air  in  the  lungs,  since  extreme  rarefaction  may 
cause  rupture  of  the  capillaries  lining  the  air-passages 
by  lessening  the  support  they  receive  from  the  intra- 
pulmonary  air-pressure. 

Of  the  above  modes  of  breathing,  the  inspiration  of  con- 
densed, and  the  expiration  into  rarefied  air  have  been  most 
frequently  emploj-ed  for  therapeutical  purposes.  These  two 
methods  may  with  advantage  be  combined,  the  patient  alter- 
nately inhaling  condensed  air  and  expiring  into  rarefied  air. 
The  high  pressure  at  which  the  air  streams  into  the  lungs 
causes  a  complete  expansion  of  the  vesicles,  and  thus  many 
vesicles  may  be  expanded  which  are  habitually  in  a  state  of 
semi-collapse.  On  the  other  hand,  expiration  into  rarefied 
air  causes  a  more  complete  removal  of  the  air  than  is 
otherwise  possible.  By  the  combined  methods  we,  in  short, 
increase  the  expansion  and  contraction  of  the  vesicles,  and 
thus  augment  the  absorption  of  oxygen  and  the  elimina- 
tion of  carbonic  acid.  ' 


CHAPTEE  XV. 

INFLUENCE  OF  THE  RESPIRATORY  MOVEMENTS  ON 
THE  CIRCULATION  OF  LYMPH. 

A  WORD  as  to  the  course  of  the  pulmonary  lymphatics. 
The  radicles  of  the  pulmonary  lymphatics  originate  in  the 
septa  between  the  alveoli  and  in  the  bronchial  mucous 
membrane,  those  from  the  superficial  alveoli  passing  into 
the  subpleural  lymphatics,  which  also  receive  the  radicles 
of  the  pleura,  while  those  from  the  deeper  alveoli  pass 
into  lymphatic  vessels  running  in  the  adventitia  of  the 
larger  bloodvessels  (perivascular  lymphatics).  The  bronchial 
lymphatic  radicles  empty  themselves  into  the  lymphatic 
vessels  situated  in  the  bronchial  adventitia  (peribronchial 
lymphatics).  All  three  groups  of  efferent  vessels — sub- 
pleural, perivascular,  and  peribronchial — traverse  the  roots 
of  the  lungs  and  pass  into  the  bronchial  glands,  whence 
the  lymph  is  conveyed  into  the  thoracic  ducts. 

The  alveolar  radicles  communicate  with  the  alveoli  through 
certain  inter-endothelial  spaces,  and  in  a  similar  manner  the 
radicles  in  the  bronchial  mucous  membrane  have  communi- 
cation with  the  interior  of  the  bronchi.  Hence  it  is  that 
particles  of  carbon  or  other  substances  in  the  air-passages 
are  able  to  work  their  way  into  the  pulmonary  lymphatics, 
and  thence  into  the  bronchial  glands.  Hence,  also,  inflam- 
matory exudations  into  the  air-passages  are  capable  of  being 
absorbed  by  the  lymphatics.     Just  as  the  bronchial  and 


INFLUENCE   ON   THE   CIRCULATION   OF   LYMPH      107 

alveolar  lymphatic  radicles  communicate  with  the  air- 
passages,  80  the  pleural  radicles  communicate  with  the 
pleural  cavities,  the  communication  in  this  case  being 
established  by  means  of  somata* 

We  are  now  in  a  position  to  explain  the  influence  of  the 
respiratory  movements  on  the  How  of  pulmonary  and 
pleural  lymph.  During  inspiration  the  openings  of  the 
pleural  stomata  become  widened,  and  the  pleural  lymphatics 
expanded  ;  hence  any  fluid  there  may  be  in  the  pleurne  tends 
to  be  drained  off  into  the  pleural  lymphatics.  During  ex- 
piration the  lymph  is  pressed  mward  in  the  latter  vessels. 
Similarly  as  regards  the  lymphatics  w^hich  take  their  origin 
in  the  bronchi  and  alveolar  septa;  inspiration  tends  to  suck 
fluid  from  the  air-passages,  expiration  to  accelerate  the 
pulmonary  lymph-flow.  Inspiration,  be  it  noted,  expands 
all  the  pulmonary  and  pleural  lymphatics,  large  and  small ; 
its  effect,  therefore,  must  be  to  suck  fluid  from  the  radicles 
into  the  larger  lymphatics.  It  must  further  be  observed 
that  all  the  pulmonary  lymphatics,  save  the  capillaries, 
being  provided  with  valves,  t  expiration  must  force  the  lymph 
along  these  vessels  in  the  same  way  as  rhythmical  muscle- 
contractions  drive  the  blood  along  the  muscle-veins. 

The  above  considerations  prepare  us  for  the  conclusion 
that  respiratory  exercises  are  useful  in  promoting  the 
absorption  of  fluid  from  the  pleuriie  and  air-passages.  Their 
potency  in  the  former  respect  is  shown  by  injecting  a  fluid 
into  the  pleura  of  an  animal,  and  observing  the  effect  of 
artiticial  respiration.  This  is  found  greatly  to  increase  the 
rate  of  absorption. 

The  central  tendon  of  the  diaphragm  contains  an  elaborate 
system  of  IjTiiphatics,  and  the  effect  of  diaphragmatic  move- 

*  See  on  the  above  subject  '  The  Anatomy  of  the  Lymphatics.' 
E.  Klein,  London,  1875. 

t  Thus  dift'ering  from  the  pulmonary  veins,  which  have  no  valves. 


108  RESPIRATORY   EXERCISES 

ments  is  to  pump  lymph  from  the  peritoneal  cavity  into  the 
pleurse,  as  can  be  shown  by  injecting  a  coloured  fluid  into 
the  former.  The  more  active  the  diaphragmatic  move- 
ment, the  more  rapidly  does  absorption  occur.  In  my 
belief,  ascites  is  often  prevented  by  active  movement  of  the 
diaphragm. 

Insi)irations  favour  the  flow  of  lymph  along  the  thoracic 
ducts  by  diminishing  the  pressure  in  the  veins  into  which 
they  respectively  enter.  On  the  other  hand,  regurgitation 
of  blood  into  the  ducts  during  expiration  is  prevented  by 
the  valves  situated  at  their  venous  openings. 

I  would  lay  particular  stress  on  the  fact  that  by  means 
of  respiratory  movements  we  are  able  to  promote  the  flow 
of  lymph,  for  in  this  way  we  can  influence  the  nutrition  of 
the  entire  body.  Consider,  for  instance,  the  case  of  the 
brain.  The  more  active  the  breathing,  the  more  rapid  is 
the  flow  of  cerebral  lymph,  and  when  we  consider  that  by 
means  of  suitable  respiratory  movements  we  can  also 
hasten  the  return  of  the  cerebral  blood,  it  is  clear  that  we 
have  at  our  command  a  ready  means  of  massaging  the 
brain.  Bearing  upon  this  subject  is  the  observation  of  a 
German  writer,  who  says  :  '  Kise  from  your  table,  take 
deep  inhalations,  move  your  arms  in  rhythm  with  them, 
and  your  ideas  are  clarified  and  your  conclusions  become 
logical.'* 

These  considerations  led  me  to  expect  that  much  good 
might  be  done  by  respiratory  exercises  in  functional  nervous 
diseases,  and  such  I  have  found  to  be  the  case.f 

The  movements  of  respiration  further  promote  the  flow 
of  lymph  in  the  pericardium,  heart,  and  chest-walls. 

*  Bril.  Med.  Jour.,  1895,  vol.  i.,  p.  93. 
t  See  Chapter  XXIV. 


CHAPTEK  XVI. 

PHYSIOLOGICAL  MODIFICATIONS  IN  THE  RESPIRATORY 
MOVEMENTS. 

We  have  seen  that  the  respiratory  movements  have  wide- 
reachmg  effects  :  that  while  primarily  serving  for  the  inflow 
and  outflow  of  the  breath,  they  also  profoundly  influence  the 
circulation  of  blood  and  lymph,  and  further,  by  rhythmical 
compression  and  dislocation  affect  the  functions  of  the 
abdominal  and  pelvic  viscera. 

Such  being  the  case,  the  various  modifications  in 
respiratory  movements  become  of  interest,  and  demand 
our  careful  study.  These  modifications  may  be  physio- 
logical and  pathological.     I  shall  deal  first  with  the  former. 

The  respiratory  movements  are  diminished  in  depth  and 
frequency  during  sleep  and  when  the  attention  is  deeply 
engaged,  and  probably  in  both  cases,  but  certainly  in  the 
former  case,  the  mean  thoracic  capacity  is  diminished.  On 
the  other  hand,  muscle-exercise  tends  to  increase  their 
depth  and  frequency,  and  to  augment  the  mean  capacity 
of  the  chest.  The  respirations  are  also  modified  in  cough- 
ing, vomiting,  and  during  muscle-effort,  in  all  of  which 
intra-thoracic  pressure  is  increased  and  the  wonted  respira- 
tory rhythm  interfered  with.  The  rhythm  is  also  modified, 
and  intra-thoracic  pressure  increased,  though  in  a  less 
degree,  in  shouting,  singing,  crying,  yawning. 


110  IIESPIRA.TORY    EXERCISES 

Diminution  in  the  Frequency  and  Depth  of  the  Respiratory 
Movements. — The  blood  normally  tends  to  accumulate  in 
the  splanchnic  veins  during  sleep,  but  the  peculiar  con- 
dition of  the  respiratory  system  at  that  time  also  favours 
its  accumulation  in  the  right  heart  and  systemic  veins. 
The  mere  diminution  in  the  frequency  and  depth  of  the 
breaths  probably  does  not  directly  interfere  with  the  circula- 
tion, since  the  respiratory  movements  in  tranquil  breathing 
do  not  appreciably  augment  the  flow  ;  but  this  diminution 
possibly  does,  by  favouring  dyspnoea,  impede  it  indirectly, 
especially  when,  from  heart  or  lung  disease,  there  is  a 
tendency  in  that  direction.  Not  only,  however,  are  the 
respiratory  movements  shallower  and  slower  during  sleep 
than  during  the  waking  state,  but  the  mean  size  of  the  chest 
is  diminished,  and  this  diminishes  not  only  the  respiratory 
area,  but  pulmonary  suction  also,  thereby  lessening  an 
important  aid  to  the  circulation. 

This  tendency  for  the  circulation  to  stagnate  during  sleep 
helps  to  explain  the  frequent  occurrence  of  dyspnoea  at 
night-time.  In  cases  of  pulmonary  engorgement  from 
mitral  disease,  for  instance,  the  respiratory  movements  are, 
during  the  waking  state,  voluntarily  amplified,  while  the 
mean  thoracic  capacity  is  increased,  the  tendency  to  en- 
gorgement being  thereby  diminished.  During  sleep,  how- 
ever, this  voluntary  help  is  not  forthcoming,  and  the 
respirations  becoming  comparatively  quiescent  and  the 
chest  capacity  diminishing,  it  is  not  surprising  that 
the  patient  should  be  at  times  awakened  by  dyspnoea.  The 
best  way  of  guarding  against  this  difficulty  is  to  instruct 
him  to  take  several  deep  breaths  before  sleep  and  whenever 
he  awakes.* 

*  '  The  sufferer  from  dilatation  constantly  supplements  his  reflex 
respiration  by  voluntary  deep  breaths.' — Sir  William  Broadbent. 

'  Take  away  the  necessity  for  the  voluntary  effort  indispensable  to 


MODIFICATIONS    IN    RESPIRATORY    MOVEMENTS       1  1 1 

When  the  mind  is  deeply  absorbed,  the  respiratory  move- 
ments are  inhibited — they  may,  indeed,  be  temporarily  sus- 
pended, as,  for  instance,  during  the  '  breathless  attention  ' 
that  awaits  the  announcement  of  some  momentous  news 
or  follows  the  course  of  an  interesting  narrative.  More  fre- 
quently, however,  the  breathings  simply  become  slower  and 
more  shallow  than  usual.  In  such  cases  the  defective 
respirations  are  apt  to  be  interrupted  ever  and  anon  by 
a  long  sigh,  which  not  only  makes  up  for  arrears  in  blood - 
aeration  but  helps  to  unload  the  engorged  right  heart. 
There  is,  therefore,  some  physiological  foundation  for  the 
old  saying  that  '  with  every  sigh  a  drop  of  blood  leaves 
the  heart.' 

All  patients  with  mitral  trouble,  but  especially  those  en- 
gaged in  close  intellectual  work,  should  be  warned  against 
this  tendency  to  shallow  breathing  during  deep  attention. 

Increased  Frequency  and  Depth,  and  Altered  Rhythm  from 
Muscle-Exercise. — Muscle-exercise  causes  an  acceleration  and 
deepening  of  the  respiratory  movements,  and  an  increase  in 
the  mean  thoracic  capacity,  these  effects  being  due  to 
alteration  in  the  blood  bathing  the  respiratory  centres,  to 
deficiency  of  oxygen,  and  to  excess  of  carbonic  acid  and 
certain  unknown  muscle-excreta. 

As  the  breathlessness  of  muscle-exercise  becomes  pro- 
nounced, expiration  tends,  as  we  have  seen,  to  become 
shorter  than  inspiration.  The  individual  experiences  an 
increasing  difficulty  in  adequately  emptying  his  lungs. 
Hence,  especially  in  the  untrained  runner,  expiration  is  apt 
to  be  unduly  restricted.  This  evil,  as  well  as  the  tendency 
to  breathe  too  rapidly,  may  be  corrected  by  training. 

respiration  (in  certain  cases  of  bronchitis),  and  the  patient  would  soon 
be  so  sound  asleep  it  would  be  difficult  to  wake  him  :  suspend  the 
voluntary  eftbrt  by  an  opiate,  and  the  sleep  is  the  sleep  of  death.' — 
Hyde  Salter. 


112  EESPIRATORY    EXERCISES 

After  exercise,  respirations  resume  their  average  rate 
before  the  heart-beats. 

The  breathlessness  induced  by  muscular  activity  is  in 
direct  proportion  to  the  amount  of  ^York  done  in  a  given 
time,  and  is  due  to  the  blood-changes  thereby  induced, 
these  being  more  pronounced  the  greater  the  amount  of  work. 
The  more  adequately  the  individual  breathes  durmg  active 
exercise,  the  less  is  the  breathlessness,  whereas  muscular 
efforts  which  lead  to  fixation  of  the  chest  cause  great 
breathlessness. 

The  augmented  activity  of  the  respiratory  movements 
consequent  upon  muscle-exercise,  favours  the  exhalation 
of  COo  and  the  absorption  of  0,  the  increased  muscle- 
metabolism  leading  to  a  greater  production  of  the  one  and 
a  greater  demand  for  the  other,  while  the  increase  in  the 
mean  size  of  the  chest  and  the  altered  rhythm  favour 
the  transit  of  blood  through  the  lungs. 

Modifications  in  the  Respiratory  Movements  leading  to 
Augmented  Intra-pulmonary  Tension. — Such  modifications 
occur  in  talking,  shouting,  singing.  These  and  kindred  acts 
are  considered  in  the  following  chapter.  Here  I  shall  refer 
only  to  those  acts  which  cause  considerable  augmentation 
of  pressure  within  the  lungs. 

In  coughing,  and  to  a  less  extent  in  sneezing,  the  lungs 
are  suddenly  compressed  by  the  contracting  chest,  and  the 
free  escape  of  air  being  impeded,  intra-pulmonary  tension 
rises.  During  the  expulsive  phase  of  vomiting,  the  glottis 
is  completely  closed,  and  the  lungs  may  be  compressed  with 
very  great  force.  In  l)oth  coughing  and  vomiting,  especially 
the  latter,  there  is  considerable  compression  of  the  abdominal 
veins  from  contraction  of  the  abdominal  muscles,  and  the. 
blood  is  in  consequence  squeezed  out  of  them  towards  the 
right  heart.  On  the  other  hand,  the  circulation  through  the 
lungs  is  impeded  owing  to  the  heightened  intra-pulmonary 


MODIFICATIONS    IN    RESPIRATORY    MOVEMENTS       113 

tension.  Hence  these  acts  engorge  the  right  heart,  and 
conduce  to  dilatation  of  its  cavities.  We  should  therefore 
use  every  endeavour  to  diminish  the  tendency  to  them, 
especially  to  paroxysmal  coughing,  which  is,  unfortunately, 
only  too  common  in  heart  disease.  An  attack  of  vomiting 
not  infrequently  gives  the  last  blow  to  a  failing  heart. 
Both  in  syncope  and  shock  the  blood  tends  to  accumulate 
in  the  abdominal  veins,  and  it  seems  probable  that  the 
vomiting  which  sometimes  accompanies  these  conditions 
may  do  good  by  driving  the  blood  thence  into  the  right 
heart. 

The  essential  features  of  cerebral  concussion  are  loss  of 
consciousness  and  shock,  the  pulse  being  very  feeble  and 
rapid  and  the  patient  blanched.  Now,  it  is  well  known 
that  the  stage  of  '  reaction,'  or  return  to  a  more  active 
circulation,  is  ushered  in  by  vomiting.  Sir  William  Savory 
used  to  teach  in  his  lectures  that  the  vomiting  did  good  by 
directly  stimulating  the  heart,  but  it  seems  much  more 
probable  that  it  benefits  by  compressing  the  great  splanchnic 
veins  and  thus  replenishing  the  right  heart,  the  inability 
of  which  to  drive  the  proper  quantity  of  blood  through  the 
lungs  is  not  due  to  any  primary  failure  of  its  own,  but  to 
dearth  of  blood-supply. 

Muscular  '  effort '  causes  fixation  of  the  chest,  generally 
in  the  position  of  inspiration.  Thus,  in  straining  at  stool, 
a  preliminary  inspiration  is  taken,  and  the  glottis  being 
closed,  the  abdommal  muscles  contract,  and,  as  a  result, 
not  only  the  abdominal  but  the  thoracic  contents  are  com- 
pressed, for  it  must  be  remembered  that  the  abdominal 
muscles  are  powerful  expirators.  Hence,  the  circulation  is 
affected  very  much  as  in  coughmg  and  vomiting,  the  blood 
being  squeezed  out  of  the  portal  system  and  inferior  cava 
into  the  right  heart,  while  its  passage  through  the  lungs  is 
greatly  impeded. 

8 


114  RESPIRATORY   EXERCISES 

This  fixation  of  the  chest  tends  to  occur  whenever  the 
large  muscles  attached  to  it  are  called  upon  to  make  powerful 
contractions,  the  object  being  to  provide  fixed  points  of 
attachment,  without  which  they  would  act  at  great  dis- 
advantage. Thus,  in  lifting  a  heavy  weight  on  to  the 
shoulders,  fixation  of  the  thorax  facilitates  the  action  of  the 
deltoids,  pectorals,  and  other  muscles  more  immediately 
engaged  in  the  process ;  while  it  also  facilitates  the  action 
of  the  muscles  occupied  in  maintaining  equilibrium  and 
in  rendering  the  vertebral  column  rigid — above  all,  the 
great  muscles  of  the  back  and  of  the  anterior  abdominal 
w^all,  which  will  be  found  to  be  powerfully  contracted.  Free 
movement  of  the  chest  is,  indeed,  quite  impossible  under 
the  circumstances.  This  remark  applies  as  much  to  the 
muscular  floor  as  to  the  bony  walls  of  the  chest,  for  it  is 
impossible  for  the  diaphragm  to  descend  when  the  anterior 
abdominal  muscles  are  powerfully  contracted. 

It  follows  that  in  all  powerful  efforts  it  is  necessary  to 
fix  the  chest,  and  it  will  generally  be  found  fixed  in  the  posi- 
tion of  inspiration.  Why  is  this  ?  One  great  advantage 
is  that  a  deep  inspiration  secures  an  extra  supply  of  oxygen 
to  compensate  for  the  failure  of  supply  during  the  period 
of  fixation.  Another  advantage  lies  in  the  diminished 
resistance  to  the  pulmonary  flow  afforded  by  the  expanded 
lungs,  this  being  especially  serviceable  at  a  time  when  the 
pulmonary  circulation  tends  to  be  obstructed  by  a  very  high 
intra-pulmonary  tension.  (It  would  not  be  surprising  if 
it  were  discovered  that  the  pulmonary  vessels  undergo  a 
vaso-motor  dilatation  at  the  same  time,  in  order  further  to 
facilitate  the  pulmonary  flow.) 

In  the  act  of  defsecation  a  full  diaphrafiinatic  inspiration 
is  taken.  This  is  manifestly  for  the  purpose  of  increasing 
intra-abdominal  tension.  In  most  cases  of  effort,  however, 
it  will  be  found  that  the  chest  is  fixed  in  costal,  not  dia- 


MODIFICATIONS    IN    RESPIRATORY    MOVEMKNTS       115 

phragmatic,  inspiration.  More  than  one  advantage  attaches 
to  this.  In  the  first  place,  more  breath  can  be  taken  in  by 
a  costal  than  by  a  diaphragmatic  inspiration.  Again, 
descent  of  the  diaphragm  would  have  the  disadvantage  of 
unduly  augmenting  intra-abdominal  tension  during  effort : 
with  the  diaphragm  low,  and  the  glottis  closed,  a  sudden 
and  violent  contraction  of  the  abdominal  muscles  might 
cause  such  an  increase  of  tension  within  the  belly  as  to  lead 
to  hernia,  not  to  mention  lesser  evils,  such  as  the  discharge 
of  faeces.  It  is  possible,  also,  that  the  abdominal  muscles, 
especially  the  recti,  can  act  to  greater  advantage  in  main- 
taining equilibrium  when  the  ribs  are  raised  and  the  origins 
and  insertions  of  these  muscles  thus  more  widely  separated 
than  when  they  are  low. 

The  greater  the  resistance  to  be  overcome  the  more 
powerful  is  the  contraction  of  the  balancing  muscles  and 
the  greater  the  instinctive  desire  to  fix  the  chest.  Even 
the  comparatively  gentle  '  resisted  movements  '  employed 
in  the  treatment  of  heart  disease  are  sufficient  to  fix  it. 
The  tendency  is  less  in  carrying  than  in  lifting  weights,  but 
in  violent  spasmodic  efforts,  as  in  jumping  and  in  wielding 
the  sledge-hammer,  the  chest  is  almost  invariably  fixed  ;  in 
hundred-yards'  sprinting  it  is  by  some  fixed  during  the 
entire  race ;  mountain-climbing,  also,  is  liable  to  cause  its 
temporary  fixation. 

That  fixation  of  the  chest  tvith  'partially  or  completely 
closed  glottis  interferes  with  the  circulation,  is  a  fact  of 
great  practical  importance.  It  shows  that  fixation  should  be 
avoided  as  far  as  possible,  and  especially  by  those  with 
heart  or  lung  disease.  A  farther  reason  for  its  avoidance 
is  that  it  tends  to  stretch  the  alveoli,  and  thus  to  diminish 
pulmonary  elasticity. 

Hence  it  is  that  in  the  various  exercises  which  we  pre- 
scribe we  are  careful  never  to  allow  the  breathing  to  stop. 

8—2 


116  RESPIRATORY   EXERCISES 

During  *  resisted  movements,'  for  instance,  we  direct  the 
patient  to  continue  to  breathe  steadily  all  the  time,  and  in 
order  to  ensure  this  it  may  be  necessary  to  make  him  count 
aloud.  Similarly,  we  must  warn  him  never  to  fix  the  chest 
when  using  the  dumb-bells.  If  the  glottis  is  closed  while 
the  dumb-bells  are  being  energetically  employed,  an  un- 
conscious expiratory  effort  is  sure  to  be  made,  and  thus 
while  strengthening  the  muscles  of  the  arm  and  chest  we 
may  be  damaging  the  lungs  and  interfering  with  the  cir- 
culation. * 


CHAPTER  XVII. 

NORMAL  MODIFICATIONS  OF  THE  RESPIRATORY  MOVE- 
MENTS (continued):  TALKING,  SHOUTING,  SINGING, 
COUGHING,  CRYING,  SIGHING. 

The  respiratory  movements  are  liable  to  constant  modifica- 
tion in  the  physiological  acts  of  talking,  shouting,  singing, 
laughing,  crying,  sighing.  These  acts  are  more  far-reaching 
in  their  effects  than  would  at  first  sight  appear.  Not  only 
do  they  affect  the  body  by  modifying  the  respiratory  move- 
ments and  thus  producing  the  effects  already  mentioned, 
but  b}'  involving  the  expenditure  of  a  considerable  amount 
of  neuro-muscular  energy,  and  by  inducing  definite  psychic 
phenomena  which  themselves  have  their  physical  accom- 
paniments. In  brief,  any  one  of  these  acts,  e.g.,  singing, 
causes  (a)  a  modification  in  the  circulation  of  blood  and 
lymph,  (b)  an  alteration  in  the  functions  of  the  abdominal 
and  pehic  \ascera  ;  and  further  leads  to  (c)  a  consider- 
able discharge  of  nerve  and  muscle  energy,  and  to 
(d)  numerous  changes  (muscular,  glandular  and  other) 
throughout  the  body,  in  consequence  of  the  attendant 
psychic  change. 

Seeing,  then,  how  far-reaching  are  the  effects  of  these 
several  acts,  and  remembering  how  large  a  part  they  play 
in  normal  life,  we  may  safely  conclude  that  they  influence 
the  functions  of  the  body  beneficially,  and  that  an  undue 


118  RESPIRATORY   EXERCISES 

interference  with  them  is  injurious.  One  is  apt  to  forget 
how  strong  is  the  instinct  to  shout  and  sing,  laugh  and  cry. 
It  is  especially  noticeable  in  the  savage  and  in  the  child. 
If  this  instinct  is  unduly  repressed  in  the  child,  it  is  sure 
to  suffer.  Crying  should  certainly  be  restrained  within 
limits,  but  there  can  be  no  doubt  that  it  is  primarily  phy- 
siological, not  only  favouring  the  proper  expansion  of  the 
lungs  and  accelerating  the  circulation,  but  deadening  the 
effects  of  pain  and  relieving  nerve-tension  (especially  in 
women) . 

Eosbach  thinks  it  not  improbable  that  many  evils  which 
manifest  themselves  in  later  life,  such  as  chlorosis,  con- 
tracted chest,  and  the  phthisical  habit,  may  take  their 
origin  in  the  practice  of  mothers  '  stopping  their  infants  from 
screaming  by  soothing  them  to  sleep  in  their  arms,  or  by 
stupefying  rocking  m  the  cradle.'* 

It  is  well  known  that  children  show  a  strong  instinct  to 
chatter  and  smg  the  first  thing  in  the  morning,  and  it 
should  be  allowed  full  vent,  as  far  as  is  practicable.  The 
shouting  which  young  people  indulge  m  during  their  play 
is  quite  remarkable,  and  is  manifestly  physiological.  The 
same  tendency  to  shout  is  observed  in  young  adults,  espe- 
cially among  the  poorer  classes,  in  holiday  time.  Though 
from  the  physiological  point  of  view  justifiable  and  even 
beneficial,  the  noises  they  make  are  certainly  not  always 
pleasing,  especially  to  the  over- sensitive  nerves  of  the 
cultured,  among  whom  this  instinct  is  consequently  sup- 
pressed, though  whether  altogether  to  the  gain  of  the  indi- 
vidual is  questionable. 

The  various  acts  referred  to  will  now  be  considered  indi- 
vidually. 

Talking.  —  As  regards  the  psychic  aspect  of  talking, 
thought  becomes  much  more  vivid  if  it  finds  expression, 

*  Von  Ziemssen's  '  Handbook  of  General  Therapeutics,'  London, 
vol.  iii.,  p.  .581. 


TALKING  119 

whether  in  speech,  writin<T,  music,  or  artistic  production, 
than  if  it  remains  unexpressed.  The  physical  effects  of 
thought  are  more  pronounced  in  talking  than  in  writing. 
The  cortical  nervous  discharges  underlying  it  send  a  stream 
of  energy  towards  the  muscles  involved  in  speech  and 
gesture,  and  both  voice  and  gesture  can  be  modified  to 
convey  subtle  shades  of  thought  and  feeling  which  cannot 
find  expression  in  writing.  The  very  expression  of  these 
subtleties  enhances  the  vividness  and  intensity  of  menta- 
tion. Talking  is  for  this  reason  stimulating,  and  its 
influence  in  this  respect  is,  in  a  measure,  proportional  to 
the  gesture  accompanying  it.  Few  things  are  more  cal- 
culated to  stimulate  the  body,  to  rouse  it  from  lethargy,  than 
'  animated '  conversation. 

In  talking,  as  in  laughing,  shouting,  singing,  and 
crying,  inspiration  is  short  while  expiration  is  prolonged, 
the  exit  of  air  being  checked  partly  by  obstruction  in 
the  glottis  and  partly  by  the  action  of  the  inspiratory 
muscles. 

The  actual  amount  of  work  done  in  talking  is  far  more 
than  might  at  first  sight  be  supposed,  and  should  always 
be  taken  into  account  in  reckoning  up  the  quantity  of 
'  exercise '  taken  during  the  day.  The  talking  done  by 
barristers,  politicians,  teachers,  and  others,  enables  them  to 
dispense  largely  with  exercise  as  ordinarily  understood. 
For  not  only  do  they  in  this  way  expend  a  considerable 
amount  of  muscle  energy,  but  they  experience  the  mani- 
fold advantages  of  active  respiratory  movement  continued 
for  long  periods  together.  Indeed,  I  believe  talking  to  be 
distinctly  conducive  to  longevity. 

That  talking  involves  a  considerable  expenditure  of  energy 
is  shown  by  the  exhaustion  which  it  induces  in  those  who 
are  nervously  run  down.  Such  are  often  greatly  exhausted 
even  after  a  moderate  day's  talking.     This  exhaustion  is 


120  RESPIRATORY  EXERCISES 

due  to  mental  as  well  as  to  muscle  expenditure.  Indeed, 
in  the  very  neurasthenic  the  bare  process  of  thought  may 
be  an  effort,  and  the  mere  effort  to  think  may  alone  cause 
exhaustion  ;  and  if  such  is  the  case,  how  much  more  likely 
is  the  putting  of  thought  into  speech  to  do  so,  seeing  that, 
apart  from  the  muscle  expenditure  involved  in  speech, 
thought  is  so  much  more  intense  when  spoken  than  when 
unexpressed. 

Talking  may  be  classified  under  the  heads  of  colloquial 
speech,  public  speaking,  and  recitatioii,  under  which  we 
may  include  reading  aloud.  In  all  three  the  breathing 
should  be  as  much  as  possible  of  the  lower  thoracic  type. 
The  amplitude  of  respiratory  movements  required  in  colloquy 
is  much  less  than  that  needed  in  public  speaking  and  reci- 
tation, in  both  of  which  it  is  necessary  to  make  the  voice 
.  travel  a  considerable  distance,  and  it  is  for  this  very  reason 
that  they  constitute  very  effective  respiratory  exercises. 
Broadbent  has  remarked  upon  the  beneficial  influence  of 
preaching  in  heart  disease.  The  good  effect  is  here  doubt- 
less due  to  the  increased  amplitude  of  the  respiratory  move- 
ments, and  to  the  help  thus  afforded  to  the  pulmonary 
circulation.  It  is  for  this  reason  that  I  always  encourage 
talking  in  those  suffering  from  passive  engorgement  of  the 
lungs, 

,  The  breathlessness  due  to  dilatation  of  the  heart  '  is 
often  relieved,'  observes  Sir  William  Broadbent,  '  by  ex- 
ercise of  the  voice.  I  have  met  with  numerous  instances 
in  which  a  clergyman  has  climbed  into  the  pulpit  with  the 
utmost  difficulty,  and  has  not  only  preached  a  sermon 
comfortably,  but  has  been  all  the  better  for  it.'*  The  good 
result,  I  take  it,  in  these  cases,  is  attributable  to  the  deep 
inspirations  necessitated  by  the  loud  voice  required  to  fill  a 
large  building. 

*  See  letter  by  the  writer,  LanccI,  1891,  vol.  i.,  p.  798. 


SHOUTING  121 

For  those  not  engaged  in  public  speaking,  and  in  whom 
it  is  hopeless  to  attempt  to  cultivate  the  singing  voice,  I 
recommend  recitation,  and,  if  that  does  not  seem  practicable, 
simple  reading  aloud.  I  believe  that  all,  save  the  mentally 
deficient  and  those  having  some  serious  defect  of  speech, 
are  capable  of  being  taught  to  recite  fairly  well,  but  a  belief 
to  the  contrary  being  deep-rooted  in  some,  we  may  be  unable 
to  persuade  them  to  learn.  In  such  cases  we  can  generally 
get  the  patient  to  read  aloud  a  quarter  of  an  hour,  or  ten 
minutes,  every  day.  In  reading,  the  individual  should 
stand,  and  the  book  should  either  be  supported  on  a  rest  a 
little  below  the  level  of  the  head,  or  it  should  be  held  out 
at  arm's  length  at  the  same  level,  the  voice  being  directed 
above  the  l^ook.  This  should  never  be  allowed  to  rest  with 
its  lower  edge  against  the  chest,  as  is  the  custom  with  some 
clergymen  at  certain  parts  of  the  service. 

Voice-production  should  be  taught  by  a  competent  teacher. 
It  is  well  to  inspire  as  much  as  possible  through  the  nose, 
especially  in  speaking  in  crowded  assemblies.  The  vast 
importance  of  breathing  through  the  nose  whenever  pos- 
sible, has  been  so  much  insisted  upon  of  late  years,  espe- 
cially by  throat  and  nose  specialists,  that  it  needs  no  further 
insistence  here.  It  is  now  fully  recognised  that  habitual 
mouth  -  breathing  is  productive  of  untold  evils,  and  that 
any  obstruction  to  adequate  nose-breathing  should  be 
promptly  removed. 

Shouting. — The  psychic  accompaniment  of  shouting  is 
essentially  emotional.  Emotion  is  not  only  expressed  but 
sustained,  and  indeed  intensified  by  it.  Thus  the  shouting 
of  children  at  play,  itself  the  outcome  of  exuberant  emotion 
and  pent-up  neuro-muscular  energy,  enhances  the  emotional 
outburst.  In  like  manner,  the  hurrahs  of  an  applauding 
multitude,  the  cry  of  the  huntsman,  the  war-whoop  of  the 
savage,   the   yells   of    an   attacking    force,   may   so   exalt 


122  RESPIRATORY    EXERCISES 

emotionality  as  to  induce  a  condition  bordering  upon 
ecstasy. 

A  further  effect  of  shouting  is  to  dull  sensibility,  the 
emotional  exaltation  which  it  provokes  and  the  voluminous 
discharge  of  neuro  -  muscular  energy  accompanying  it, 
inducing  a  corresponding  depression  in  the  sensorial 
sphere.  It  is  on  this  principle  that  groaning,  and  still 
more  the  shriek  of  acute  agony,  brings  relief ;  the  mere 
sound  produces  a  similar  effect  by  violently  energizing  the 
acoustic  centres.* 

The  shouting  and  gesticulation  which  accompany  an 
outburst  of  passion  act  physiologically  by  relieving  nerve 
tension,  and  indeed,  as  Hughlings  Jackson  has  suggested, 
swearing  may  not  be  without  its  physiological  justification. 
Passionate  outbursts  are  generally  succeeded  by  a  period 
of  good  behaviour,  and,  it  may  be,  improved  health.  One 
frequently  notices  this  in  children,  and  I  have  also  noticed 
it  in  the  adult.  It  is  possible  that  the  outbursts  of 
irritability  observed  in  disease,  as  for  instance  in  gout, 
have  their  physiological  as  well  as  their  pathological 
aspect. 

As  regards  the  modifications  in  the  respiratory  move- 
ments caused  by  shouting,  the  important  practical  point 
to  notice  is  that  they  are  increased  in  depth.  Hence, 
shouting  favours  the  development  of  the  lungs  and 
accelerates  the  circulation  of  blood  and  lymph. 

Singing. — Singing,  like  shouting,  is  more  emotional  than 
intellectual,  the  degree  of  emotion  called  forth  depending 
upon  the  extent  to  which  the  individual  throws  himself 
into  the  spirit  of  the  song.  The  nature  of  the  attendant 
emotion  varies,  of  course,  considerably,  and  there  is  a 
corresponding   variability  in  its  physical  correlatives.     If 

*  A  famous  quack  extracts  his  patients'  teeth  to  the  blare  of  trumpets 
and  the  boom  of  a  big  drum. 


SINGING  123 

the  theme  of  the  song  be  joyous,  the  proper  rendering  of 
it  is  highly  stimulating. 

In  singing  there  is  a  great  disproportion  between  inspira- 
tion and  expiration,  the  latter  being  much  the  longer. 
Moreover,  durmg  these  long  expirations,  the  glottis  is 
constricted,  and  the  free  egress  of  air  thus  being  prevented, 
ntra-pulmonary  air-tension  rises,  and  consequently  the  flow 
of  blood  to  and  from  the  right  heart  is  impeded ;  but  this 
temporary  retardation  of  the  blood-flow  is  reduced  to  a 
minimum  by  the  expert  singer,  whose  notes  flow  out  without 
appreciable  eflbrt,  and  is  more  than  compensated  for  by  the 
acceleration  which  takes  place  during  the  succeeding  deep 
inspiration.  The  obstruction  at  the  glottis  increases  as  the 
scale  is  ascended,  and  seeing  that  the  expiratory  force  em- 
ployed in  the  delivery  of  the  upper  notes  is,  for  the  most 
part,  greater  than  that  employed  in  the  production  of  the 
lower,  it  follows  that  high  singing,  especially  if  fortissimo, 
impedes  the  circulation  more  than  low  singing. 

I  am  not  as  a  physician  greatly  concerned  with  the 
method  of  breathing  employed,  provided  it  be  not  the 
exaggerated  collar-bone  type,  which  I  emphatically  depre- 
cate. On  the  whole,  I  am  inclined  to  recommend  the 
costo-abdominal  type.  It  should  be  observed  that  when 
the  diaphragm  is  actively  used,  the  effect  on  the  abdomino- 
pelvic  viscera  is  greater  than  is  otherwise  the  case. 

From  the  medical  standpoint  singing  is  a  most  important 
exercise,  both  by  virtue  of  its  influence  on  the  emotions,  on 
the  respiratory  movements,  and  on  the  development  of  the 
lungs.  Nothing  better  shows  the  beneficial  effect  of  singing 
hi  developing  the  chest  and  wardmg  off  lung  disease  than  the 
great  pulmonary  development  and  freedom  from  pulmonary 
disease  among  professional  singers.  Their  general  health 
is,  moreover,  exceptionally  good,  and  this  is  probably  in 
large  measure  attributable  to  the  mere  exercise  of   their 


124  RESPIRATORY    EXERCISES 

calling.*  Such  therapeutic  importance  do  I  attach  to  sing- 
ing that  I  recommend  it  wherever  opportunity  affords.  It 
is  especially  useful  in  defective  chest  development  and 
in  chronic  heart  disease.  Provided  the  patient  can  sing 
with  comfort,  I  know  of  no  condition  in  which  singing  is 
contra-indicated,  unless  it  be  a  tendency  to  tubercular  or 
aneurysmal  haemoptysis.  It  is  scarcely  necessary  to  say 
that  the  singer  should  be  so  clad  as  to  allow  absolute 
freedom  of  the  chest-movements  :  there  should  be  no  con- 
striction of  the  neck  or  waist,  the  collar  should  be  low  and 
ample,  the  stays  (if  worn)  pliant  and  loose. 

Oertel  speaks  enthusiastically  of  the  beneficial  influence 
of  singing  on  the  general  health,  and  especially  on  the 
lungs,  and  he  refers  to  the  fact  that  almost  all  eminent 
singing-masters  can  tell  of  serious  cases  of  lung  disease 
which  have  been  cured  by  their  particular  method  of  singing. 
He  thinks  there  can  be  no  doubt  that  weak  chests  of  various 
kinds  can  be  greatly  improved  by  it,  and  he  would  even 
appear  to  include  phthisis.  '  In  consequence  of  the  reports 
sent  in  from  various  quarters  on  the  healthy  influence  of 
singing  on  the  respiration  and  circulation,  and  on  the 
strengthening  and  nutrition  of  the  lung,  the  practice  of 
singing  has  been  introduced  even  into  prisons,  in  order 
to  antagonize  pulmonary  consumption,  which  generall}^ 
develops  in  a  short  time  among  the  convicts.  The  method 
of  singing  devised  by  Fried.  Grell  is  especially  adapted  for 
our  national  schools,  and  ought  to  be  generally  introduced, 
like  gymnastics,  from  a  sanitary  point  of  view.'t 

The  invigorating  effect  of  singing  is  well  shown  by  the 

*  The  splendid  chest  development  of  public  singers  is,  of  coui'se,  not 
entirely  attributal)lc  to  the  constant  exercise  of  the  voice,  since  no  one 
can  attain  a  high  excellence  without  having  a  good  chest  development 
in  the  first  instance.  It  must  also  be  observed  that  every  singer  who 
attains  to  fame  is  careful  to  lead  a  healthy  life. 

t  Von  Ziemssen's  'Handbook  of  General  Therapeutics,' vol.  iii., 
p.  583. 


LAUGHTER — CRYING  125 

following  extract  from  a  daily  paper  :  '  The  Artists  (Volun- 
teers) have  a  collection  of  marching  choruses  which  are 
peculiarly  their  own,  and  from  long  practice  they  are 
ahle  to  get  every  ounce  of  effect  out  of  them.  This 
system  of  singing  is  one  which  helps  many  men  to 
keep  going  when  they  have  no  band  to  back  them  up,  and 
it  is  astonishing  to  see  the  change  in  the  bearing  of  the 
men  when,  perhaps  towards  the  end  of  the  day,  and  they 
are  a  bit  done,  someone  strikes  up  a  song  with  a  rousing 
chorus.  The  lagging  steps  become  elastic,  backs  straighten 
up,  and  with  a  soldierly  swing  the  men  go  on,  and  forget 
for  the  while  that  they  have  a  blistered  heel  or  the  uncom- 
fortably heavy  equipment.' 

Laughter. — The  psychic  accompaniment  of  laughter  being 
joyous  emotion,  its  effect  is  stimulating,  and  it  has  been 
truly  said  that  the  man  who  makes  us  laugh  is  a  public 
benefactor.  Its  beneficial  effect  on  the  body  is  illustrated 
in  the  saying,  '  Laugh  and  grow  fat.'  The  expiratory  act 
in  laughter  is  greatly  prolonged,  and  the  glottis  being  partly 
closed,  intra-pulmonary  tension  is  increased,  and  thus  in 
excessive  laughter  there  may  be  considerable  impediment 
to  the  flow  of  blood  through  the  lungs,  as  shown  by  the 
turgid  head  and  neck.  This  disadvantage — for  in  most 
cases  of  heart-disease  it  is  a  disadvantage — is  far  more  than 
compensated  for  by  other  effects,  foremost  among  which 
must  be  reckoned  the  deep  inspirations  which  separate  the 
individual  paroxysms. 

Crying. — In  thinking  of  the  term  crying,  one  must  dis- 
tinguish between  the  mere  shedding  of  tears  and  the  weeping 
accompanied  by  sobbing.  In  the  one  the  effects  are 
limited,  while  in  the  other  the  entire  body  may  be  violently 
convulsed. 

I  have  already  referred  to  the  beneficial  effects  of  crying 
in  children. 


126  RESPIRATORY   EXERCISES 

The  crying  of  the  infant  is  peculiar.  Expirations  are 
prolonged,  sometimes  for  as  much  as  half  a  minute,  and 
are  interrupted  by  short  inspirations.  During  the  expira- 
tions the  glottis  is  contracted,  and  the  intra-pulmonary 
pressure  rises  considerably.  Not  only  is  the  pulmonary 
circulation  thereby  greatly  impeded,  as  shown  by  the  swollen 
veins  of  the  head  and  neck,  but  bronchial  mucus,  flatus, 
and  other  noxious  matters  are  evacuated.  The  paroxysm 
is  succeeded  by  rapid  deep  respirations,  which  restore  the 
equilibrium  of  the  circulation.  Women,  likewise,  often 
derive  benefit  from  '  a  good  cry  ';  the  jDrofuse  flow  of  tears 
lessens  blood-pressure  within  the  cranium ;  the  voluminous 
discharge  of  nerve-energy  relieves  nerve-tension  ;  the 
sobbing  movements  of  respiration  influence  in  a  very  de- 
cided and  doubtless  beneficial  way  the  circulation  and  the 
movements  of  the  abdomino-pelvic  viscera ;  while  the  wide- 
spread contraction  of  the  muscle  system  has  probably 
also  a  good  effect.  How  pronounced  are  the  dynamic 
effects  induced  by  completely  abandoning  one's  self  to  a  fit 
of  crying  is  shown  by  the  exhaustion  which  it  entails.  It 
is,  perhaps,  partly  through  this  exhaustion  that  crying 
induces  sleep — we  hear  of  '  crying  one's  self  to  sleep  ' — 
though  this  must  be  but  a  very  crude  explanation  of  the 
phenomenon. 

The  tendency  of  women  to  cry  should,  of  course,  be  kept 
within  proper  bounds,  but  certainly  harm  may  result  from 
its  complete  suppression,  as  Tennyson  recognises  in  the 
line,  '  She  must  weep  or  she  will  die.'  (It  is  said  that 
women  who  are  able  to  find  relief  in  tears  keep  their  youth 
longer  than  those  who  repress  them.)  The  cankering  action 
of  a  long-continued  pent-up  emotion  has  been  likened  to  a 
*  worm  i'  the  bud.'  This  is  no  mere  poetic  conceit,  but  ex- 
presses a  profound  physiological  truth.  In  short,  strong 
emotion  should  find  expression.     '  Give  sorrow  words.' 


YAWNING  127 

The  sigh  of  syncope  is  comparatively  rare.  A  much  more 
common  cause  of  sighing  is  shallow  breathing,  however 
induced.  Thus,  sadness  and  a  sense  of  weariness  or 
boredom  are  wont  to  be  attended  by  shallow  breathing, 
and  in  all  of  them  sighing  is  frequent.  In  consequence  of 
this  shallow  breathing  blood-aeration  lags  behind,  and  the 
blood  tends  to  accumulate  in  the  right  heart  and  systemic 
veins.  The  sigh  benefits  by  promoting  the  aeration  of  the 
blood  and  by  quickening  the  pulmonary  circulation.  It  is 
for  similar  reasons  that  sighing  is  apt  to  occur  during 
'  breathless  attention ' — when  the  attention,  i.e.,  is  so 
strained  that  one  forgets,  as  it  were,  to  breathe  adequately. 

Yawning. — It  is  difficult  to  describe  accurately  this  act. 
A  deep  and  prolonged  inspiration  is  taken  through  the 
mouth  and  nose,  the  mouth  being  widely  opened  and  the 
nares  dilated.  The  opening  of  the  mouth  is  effected  by  a 
strong  tonic  contraction  of  the  depressors  of  the  lower  jaw, 
and  by  the  extension  of  the  head  and  consequent  elevation 
of  the  upper  jaw.  At  the  same  time  the  limbs  and  trunk 
are  *  stretched.'  There  is,  in  short,  a  wide-spread  tonic  con- 
traction of  the  muscle  system.  This  continues,  and  indeed 
reaches  its  climax,  during  the  expiratory  portion  of  the  act, 
the  mouth  being  kept  open  till  towards  the  end  of  it.  The 
expiratory  current  is  directed  solely  through  the  mouth 
owing  to  elevation  of  the  soft  palate,  and  the  vocal  cords 
approximate,  a  characteristic  sound  being  produced  in  the 
larynx,  while  there  is  a  peculiar  contraction  of  muscles  at 
the  back  of  the  throat,  the  nature  of  which  I  do  not  under- 
stand. 

There  can  be  little  doubt  that  one  of  the  objects  of 
yawning  is  the  exercise  of  muscles  which  have  been  for  a 
long  time  quiescent,  and  the  acceleration  of  the  blood-  and 
lymph-flow,  which  has  in  consequence  of  this  quiescence 
become    sluggish.      Hence,    its   frequency   after   one   has 


128  RESPIRATORY   EXERCISES 

remained  for  some  time  in  the  same  position,  e.t).,  when 
waking  in  the  morning.  Co-operating  with  this  cause  is 
sleepiness,  and  the  shallow  breathing  which  it  entails. 
This  factor,  as  well  as  muscle-quiescence,  is  apt  to  attend 
the  sense  of  boredom.  Hence  it  is  that  the  bored  individual 
is  apt  to  yawn.  As  in  the  case  of  sighing,  the  deep  breath 
which  attends  the  act  of  yawning  compensates  for  the 
shallow  breathing  which  is  so  apt  to  excite  it. 
,  I  am  unable  to  offer  any  explanation  of  the  yawning,  or 
rather  gaping,  which  is  induced  by  exhaustion  from  want 
of  food.  This  mere  gaping  is,  however,  quite  distinct  from 
yawning,  which  is  a  much  more  complex  phenomenon. 

Allied  to  yawning  is  a  modification  of  the  breathing 
which  is  apt  to  occur  during  sleep.  A  deep  breath  is 
taken  more  or  less  suddenly,  and  this  is  followed  by  a 
long  -  drawn  -  out  expiration  with  partially  closed  glottis, 
accompanied  by  a  groaning  sound.  This  kind  of  breath- 
ing has  certainly  some  physiological  import,  but  what  it  is 
I  cannot  say. 


CHAPTER  XVIII. 

IMPEDIMENTS  TO  THE  RESPIRATORY  MOVEMENTS. 

Defective  expansibility  of  the  lungs  is  a  potent  cause  of 
restricted  respiratory  movements,  and  since  all  diseases  of 
the  lungs  diminish  this  expansibility,  they  all  curtail  the 
respiratory  movements.  Phthisis,  emphysema,  and  pneu- 
monia are  instances  in  point.  Effusions  into  the  pleura 
and  pleuritic  adhesions  also  limit  pulmonary  expansion, 
the  latter  by  interfering  with  the  movement  of  the  lungs 
within  the  chest.* 

Affections  of  the  heart,  pericardium,  and  aorta  may  like- 
wise impede  the  movements  of  respiration.  Amongst  these 
may  be  mentioned  pericardial  effusion,  agglutination  of  the 
heart  to  the  chest-wall,  aortic  aneurysm,  and  enlargement 
of  the  heart.  The  latter  produces  its  effect  by  encroaching 
upon  the  lungs,  and  in  a  child  especially,  this  encroach- 
ment may  be  considerable. 

It  will  be  convenient  to  consider  the  impediments  to 
costal  and  diaphragmatic  breathing  individually. 

Impediments  to  Costal  Breathing. — (a)  The  intra-thoracic 
diseases  above  referred  to.  The  limitation  of  costal  breath- 
ing thus  induced  tends  to  be  most  marked  in  those  ribs 

*  John  Hutchinson  {op.  cit.)  refers  to  a  case  in  which  post-mortem 
examination  disclosed  complete  adhesions  of  both  pleurae,  and  in  which 
the  vital  capacity  during  life  was  above  the  average.  It  is  difficult  to 
explain  such  a  case. 

9 


130  RESPIRATORY   EXERCISES 

which  overlie  the  disease.  Thus,  in  phthisis  the  impaired 
movement  may  involve  one  apex  only,  and  in  enlarged 
heart  and  distended  pericardium  it  may  be  confined  to  the 
superjacent  ribs,  costal  cartilages,  and  sternum. 

(b)  Changes  in  the  thoracic  wall.  Among  these  may  be 
mentioned  pleurodynia,  disease  of  the  ribs  and  contiguous 
parts,  such  as  fracture  of  the  ribs,  or  of  the  arm,  and 
inflammation  of  the  axilla,  in  all  of  which  the  limitation 
may  be  unilateral.  After  amputation  of  one  arm,  the 
motion  of  the  ribs  on  the  same  side  is  restrained. 

Lateral  and  angular  curvature  materially  interfere  with 
costal  movement,  especially  the  latter,  and  it  is  for  this 
reason  that  subjects  of  angular  curvature  are  so  prone  to 
pulmonary  disease  and  to  dilated  right  heart. 

Obesity,  especially  in  the  woman,  may  hamper  costal 
breathing,  for  though  the  ribs  may  glide  up  and  down 
under  the  overlying  fat,  this  has,  in  some  degree,  to  be 
lifted,  especially  in  the  upright  position  of  the  body. 

Eigidity  of  the  chondro-osseous  cage  also  interferes  with 
costal  breathing,  and,  as  we  have  seen,  this  rigidity  increases 
with  age.  Hence,  altogether  apart  from  the  loss  of  pul- 
monary expansibility  which  takes  place  with  advancing 
years,  there  necessarily  occurs  a  diminution  in  the  extent 
of  costal  movement ;  and  it  is  not  always  easy  to  say  how 
far  thoracic  immobility  in  the  aged  is  due  to  senile  rigidity, 
and  how  far  to  defective  pulmonary  expansibility. 

(c)  Affections  of  the  muscle-system.  Weakness  of  the 
muscle-system,  whether  from  fever,  chronic  wasting  disease, 
or  what  not,  tends  to  render  costal  breathing  sluggish. 
Hence  the  advantage  of  a  well-developed  muscle-system  in 
facilitating  costal  movement.  Oertel  believes  that  the 
beneficial  effect  of  mountain  -  climbing  in  heart-disease  is 
largely  due  to  its  influence  on  the  respiratory  muscles,  and 
I  have  no  doubt  that  such  is  the  case. 


IMPEDIMENTS  TO  THE  RESPIRATORV  MOVEMENTS     131 

(d)  Abdominal  conditions.  The  movement  of  the  lower 
ribs  may  be  restricted  by  peritonitis,  ascites,  abdominal 
tumours,  etc. 

(/')  Posture.  The  ribs  cannot  move  as  freely  in  the 
horizontal  as  in  the  vertical  posture. 

(/)  Unsuitable  clothing.  It  would  be  difficult,  if  not 
impossible,  to  devise  any  kind  of  dress  which  would  leave 
the  respiratory  movements  absolutely  unembarrassed.  The 
two  objects  to  be  aimed  at  are  lightness  and  looseness. 
There  should  be  a  minimum  of  weight  on  the  shoulders 
and  chest,  and  sufficient  looseness  to  admit  of  the  fullest 
possible  chest  expansion — that  is  to  say,  the  measurements 
should  be  taken,  not  while  the  chest  is  in  a  state  of  mean 
expansion,  but  during  extreme  inspiration.  It  is  scarcely 
necessary  to  say  that  these  requirements  are  practically 
never  complied  with.  In  women  the  bodice  is  often  made 
to  fit  the  chest  tightly,  like  a  glove,  the  measurement  across 
the  chest  bring  several  inches  less  than  it  should  be.  This 
was  especially  the  case  a  few  years  ago,  when  it  was  the 
fashion  for  women  to  be  flat-chested ;  and  even  to-day  it  is, 
I  am  told,  well-nigh  impossible  to  get  a  fashionable  dress- 
maker to  allow  ample  room  across  the  chest,  although  the 
increasing  prevalence  of  bicycling  is  undoubtedly  leading  to 
an  improvement  in  this  respect. 

A  special  evil  to  be  guarded  against  is  the  accurate  fitting 
of  the  chest  garments  to  a  misshapen  chest.  Suppose,  for 
instance,  that  a  coat  or  bodice  is  accurately  fitted  to  a 
stooping  figure,  it  is  clear  that  any  attempt  to  straighten 
the  body  and  expand  the  upper  part  of  the  chest  will  be 
hampered  by  the  clothes. 

In  the  endeavour  to  minimize  the  evils  arising  from  the 
weight  of  the  clothes,  they  must  not  only  be  made  as  light 
as  possible,  but  regard  must  be  had  to  the  points  from 
which   they   are   suspended.     *  Children,   especially   girls, 

9—2 


132  RESPIRATORY    EXERCISES 

have  to  wear  stockings,  and  to  keep  these  stockings  up  an 
elastic  suspender  is  attached,  this  being  fastened  either  to 
a  light,  stiff  jacket  or  a  corset,  which  is  kept  up  by  shoulder- 
straps  over  the  shoulders.  Then,  other  articles  of  clothing 
are  also  kept  up,  more  or  less,  by  shoulder-straps,  and  these 
straps  are  not  placed  close  to  the  neck,  where  they  would 
be  less  harmful,  but  to  the  apices  of  the  shoulders,  where 
they  constantly  tend  to  bear  the  latter  downwards  and 
forwards,  giving  rise  to  stooping  shoulders  and  to  a  poking 
head,  depressing  the  chest,  and  acting  as  a  constant  source 
of  irritation  to  the  wearer.'*  To  be  ideal  the  clothes 
should  be  partly  suspended  from  the  hips  and  partly  from 
the  shoulders,  the  attachment  being  in  the  latter  case  close 
to  the  neck. 

The  injurious  effect  of  heavy  accoutrements  on  costal 
breathing  is  sufficiently  manifest. 

I  have  reserved  to  the  last  the  effect  of  the  corset  in 
restricting  the  movements  of  the  ribs.  Even  the  most 
pliant  and  loose  stays,  such  as  Jaeger's,  though  permitting 
ordinary  breathing,  prevent  full  thoracic  expansion,  and 
ordinary  stays  are  practically  always  tightened  up  some- 
what— their  very  name  implies  this — and  they  are  decidedly 
tight  to  many  who  would  not  be  regarded  as  tight-lacers. 
Unless  the  hand  can,  without  being  in  the  slightest  degree 
compressed,  be  placed  beneath  them  during  the  fullest 
costal  inspiration,  it  is  clear  that  they  must  interfere  with 
the  expansion  of  the  lower  chest.  As  a  matter  of  fact,  the 
thorax  of  all  corset-wearers  is  distorted,  the  lower  part  of 
the  chest  being  unduly  contracted  and  immobile,  and  the 
upper  part  unduly  expanded  and  mobile;  so  that  no  woman 
who  has  habitually  worn  stays  can  be  employed  as  an  un- 
draped  model. 

We  may  here  stop  to  consider  the  evils  of  tight-lacing  in 

*  Noble  Smith,  Clin.  Jour.,  February  27,  1895. 


IMPEDIMENTS  TO  THE  RESPIRATORY  MOVEMENTS    133 

a  general  way.    The  practice  interferes  with  the  movementsv 
of  the  diaphragm  as  well  as  of  the  ribs,  with  several  evils 
as  a  result,    (a)  Respiration  is  diminished,     (h)  One  of  the 
most  important  accessory  forces  of  the  circulation  is  inter- 
fered with,  the  blood  being  no  longer  sucked  and  squeezed 
out  of  the  large  veins  into  the  right  heart  with  the  normal 
force,     (f)  The  respiratory  area  being  diminished,  the  re- 
sistance opposed  to  the  right  heart  is  increased  ;  as  a  con- 
sequence, dilatation  of  the  right  heart  is  favoured,  pressure 
in  the  pulmonary  circuit  rises,  and  there  is  accentuation  of 
the  second  sound.     This  I  find  very  frequent  in  women. 
{(I)  The  limitation  of   diaphragmatic  movement  interferes 
with  that  rhythmical  compression  and  dislocation  of   the 
abdominal  and  pelvic  viscera  which  are  intimately  bound 
up  with  the  normal  carrying  on  of  their  functions.     The 
worst  indictment  has  yet  to  come  :  (e)  The  compression  of 
the  abdominal  vessels  drives  the  blood  which  they  should 
contain  into  other  parts  of  the  vascular  system,  and  arterial 
pressure  and  the  work  of   the  heart  are,  in  consequence, 
augmented.     The  effect  on  the  heart  is,  in  fact,  the  same 
as  that  which  would  be  produced  by  increasing  the  quantity 
of  blood  in  the  body.*     (/)  Stays  also  induce  atrophy  of 
the  muscles  of   the  chest,  back,   and  anterior  abdominal 
wall,  and  it  is  largely  on  this  account  that  pendulous  belly, 
with  its  many  secondary  evils,  is  so  common  in  women.! 
Were  stays  never  worn,  and  were  the  abdominal  muscles 
properly  exercised,  this  affection  would  be  seldom  met  with. 
It  is  not  surprising  that  women,  and  even  sensible  ones, 
should  defend  the  use  of  stays.     Their  chief  argument  is 
that  '  the  figure  requires  support,'  that  *  they  feel  the  need 

*  Roy  and  Adami  have  shown  that  pressure  on  the  abdomen  may 
increase  the  work  of  the  heart  by  30  per  cent.  Brif.  Med.  Jour.,  1888, 
vol.  ii.,  p.  1321. 

t  See  Chapter  II. 


134  RESPIRATORY   EXERCISES 

of  support.'  Precisely.  This  need  is  inevitable  when  the 
muscles  of  the  chest,  back,  and  abdomen  are  imperfectly 
developed,  as  they  cannot  fail  to  be  when  stays  have  been 
habitually  worn.  The  corset,  in  short,  creates  the  demand 
which  it  supplies. 

It  is  only  among  the  obese  that  the  physiologist  can 
sanction  the  use  of  stays,  and  then  merely  as  a  temporary 
and  remedial  measure.  When  the  abdominal  walls  are 
very  flabby  the  firm  support  of  the  corset  may  render 
service  by  keeping  up  intra-abdominal  tension,  and  thus 
preventing  an  undue  accumulation  of  blood  in  the  splanchnic 
veins,  and  also  by  enabling  the  diaphragm  to  play  its  proper 
part  in  promoting  the  abdominal  circulation  (see  p.  90). 
Exercises  calculated  to  develop  the  abdominal  muscles  will, 
however,  enable  the  woman  to  dispense  with  this  artificial 
support  after  a  time,  longer  or  shorter  according  to  the 
extent  of  the  mischief. 

Now,  if  tight-lacing  is  harmful  even  in  the  normal 
individual,  how  much  more  so  must  it  be  in  the  diseased, 
above  all,  in  sufferers  from  cardiac  and  pulmonary  disease. 
The  only  wise  course  for  such  is  to  discard  stays  altogether. 
Even  loose  stays  are  hurtful  in  their  case,  for  it  is  im- 
possible to  get  them  so  loose  as  not  to  hamper  the  respira- 
tory movements ;  and  yet  I  have  over  and  over  again 
examined  women  with  severe  heart-disease  who  laced 
tightly.  I  can  recall  one  young  woman  with  a  pre-systolic 
mitral  murmur  who  was  suffering  as  much  from  constric- 
tion of  the  waist  as  of  the  mitral  orifice. 

When  we  consider  the  evils  of  tight-lacing,  the  wonder  is 
that  it  can  be  continued  for  any  length  of  time  without  leading 
to  fatal  results.  It  must,  however,  be  remembered  that  stays 
are  only  worn  during  a  portion  of  the  twenty-four  hours ; 
that  during  that  portion  they  are  not  always  tightened 
up  to  the  extreme  limit ;  and  that  when  they  are  loosened 


IMPEDIMENTS  TO  THE  RESPIRATORY  MOVEMENTS    135 

(above  all,  when  they  are  removed)  the  breathing  becomes 
more  natural  again,  the  circulation  tending  to  readjust 
itself.  I  have  satisfied  myself  that  even  in  extreme  tight- 
lacers  the  diaphragm  acts  freely  in  the  horizontal  position 
after  the  stays  are  removed.  Further,  we  may  reasonably 
assume  that  some  provision  is  made  in  the  woman  against 
impediments  to  diaphragmatic  descent,  seeing  that  such 
normally  exist  during  pregnancy.  Finally,  there  is  the 
fact  that  an  individual  rarely  lives  up  to  his  full  physio- 
logical capabilities,  and  that  there  is  normally  a  consider- 
able pulmonary  and  cardiac  reserve  power.  Were  it  not  for 
this,  tight-lacing  would  be  impossible.  A  tight-lacer  is  not 
only  compelled  to  curtail  her  activities,  but  she  draws  upon 
her  entire  reserve,  and  since  the  sufferer  from  heart  or 
lung  disease  needs  the  full  measure  of  reserve  power,  tight- 
lacing  in  her  case  is  slow  suicide. 

Impediments  to  Diaphragmatic  Breathing.  —  (a)  Intra- 
thoracic disease.  The  extent  to  which  the  diaphragm  is 
capable  of  moving  is,  of  course,  largely  dependent  upon  the 
expansibility  of  the  lungs.  Thus  in  phthisis  its  movements 
may  be  greatly  limited ;  also  in  emphysema,  which  may 
cause  such  flattening  and  descent  of  the  diaphragm  as,  so 
it  is  said,  to  nullify  completely  its  inspiratory  power,  though 
it  is  certain  that  in  many  cases  of  emphysema  the  work  of 
inspiration  is  thrown  almost  entirely  on  the  diaphragm, 
owing  to  the  immobility  of  the  ribs.  Extensive  adhesions 
of  the  lower  portions  of  the  lungs  necessarily  interfere  with 
diaphragmatic  descent,  for  if  the  lungs  cannot  move  bodily 
downwards,  they  can  only  expand  vertically  by  an  excessive 
vertical  stretching  of  the  air  vesicles. 

Pleural  and  pericardial  effusion  may,  of  course,  also 
impede  diaphragmatic  action.  It  should  be  observed  that 
when  the  intra-thoracic  disease  is  on  one  side,  the  move- 
ment on  the  corresponding  side  of  the  diaphragm  is  limited. 


136  RESPIEATORY   EXERCISES 

(b)  Disorders  of  the  diaphragm  itself.  The  diaphragm  may 
be  paralyzed  in  diphtheria  and  spinal  disease  ;  it  may  share 
in  the  weakness  of  the  muscle-system  generally  ;  it  may  be 
degenerated  in  typhoid  and  other  fevers  ;  also  in  emphy- 
sema, bronchitis,  and  heart-disease*  ;  it  may  become  in- 
flamed in  association  with  pleurisy  and  peritonitis  ;  and  it 
may  be  infected  with  trichinosis  and  malignant  disease. 

(c)  Impediments  referable  to  the  abdomen.  Acute  peri- 
tonitis may  cause  the  diaphragm  to  remain  practically 
stationary.  The  abdominal  muscles  become  tense  in  this 
condition,  so  as  to  protect  the  inflamed  surfaces,  and 
possibly  also  to  oppose  the  descent  of  the  diaphragm 
(Hutchinson).  Their  contraction,  it  should  be  noted,  con- 
tinues even  during  inspu'ation,  thus  opposing  the  action  of 
the  inspirators. 

An  enlarged  liver  does  not  generally  impede  the  action  of 
the  diaphragm  to  any  great  extent,  as  this  organ  tends  to 
increase  in  the  dov^nward  direction.  When  a  tumour 
occupies  its  upper  part,  it  may  be  thrust  upwards,  and 
limit  the  action  of  the  right  half  of  the  diaphragm.  This 
is  especially  the  case  in  hydatid  of  the  liver. 

Other  abdominal  tumours,  such  as  a  pregnant  uterus, 
fibroid,  ovarian  cyst,  or  hydronephrosis,  may  interfere  with 
the  descent  of  the  diaphragm  ;  so  also  may  obesity,  flatu- 
lent distension,  and  ascites.  These  latter  demand  a  special 
notice.  They  all  three  tend  to  thrust  the  diaphragm  up- 
wards, and  thus  to  diminish  the  pulmonary  area  and  dis- 
locate the  heart.  That  they  should  do  this  is  not  surprising, 
seeing  that  they  cause  a  considerable  increase  of  intra- 
abdominal tension,  and  that  pulmonary  suction  is  ever  tend- 
ing to  draw  the  diaphragm  upwards.  They  also  necessarily 
offer  a  considerable  obstacle  to  the  normal  flattening  of  the 
diaphragm  during  inspiration. 

*  Consult '  Virch.  Arch.,'  B.  73,  s.  166-180,  for  an  instructive  article  on 
'  The  Degenerations  of  the  Diaphragm  :  their  Causes  and  Consequences.' 


IMPEDIMENTS  TO  THE  RESPIRATORY  MOVEMENTS    137 

Although  the  movements  of  the  diaphragm  are  restricted 
when  the  walls  of  the  abdomen  are  overladen  with  fat,  the 
restriction  maj'  be  much  less  than  one  might  expect.  It  is 
astonishing  what  resistance  a  powerful  diaphragm  is  capable 
of  overcoming,  I  have  seen  a  belly  as  tight  as  a  drum  from 
excessive  accumulation  of  fat  and  fluid  rise  an  inch  or  more 
with  every  descent  of  the  diaphragm,  and  this  when  the 
patient  was  moribund.  In  such  cases  the  diaphragm  must 
be  greatly  hypertrophied. 

Since  obesity  restricts  both  costal  and  diaphragmatic 
movement,  and  at  the  same  time  curtails  the  respiratory 
area,  it  necessarily  impedes  the  circulation,  causing  the 
blood  to  flow  with  increased  difiiculty  through  the  lungs. 
Hence  the  tendency  to  hypertrophy  and  dilatation  of  the 
right  heart  in  the  obese,*  and  for  the  blood  to  be  dammed 
back  upon  the  great  veins.  The  circulation  being  sluggish, 
and  the  respiratory  action  curtailed,  the  further  formation 
of  fat  is  favoured.  Thus  fat  begets  fat.  Moreover,  the 
circulation  both  of  pulmonary  and  systemic  blood  being 
sluggish  through  the  lungs,  these  organs  are  predisposed 
to  inflammation,  and  it  is  for  this  reason  that  the  obese  are 
so  liable  to  bronchitis.  Acute  bronchitis  and  pneumonia 
are  very  dangerous  when  they  occur  in  the  stout,  on  account 
of  (a)  their  restricted  respiratory  area,  (h)  their  restricted 
respiratory  movements,  and  (c)  their  sluggish  circula- 
tion. 

These  considerations  prove  the  necessity  of  reducing  the 
quantity  of  fat  in  the  very  obese.  This  is,  above  all,  neces- 
sary in  cases  of  pulmonary  and  cardiac  disease.  With  me 
it  is  alwaj^s  a  first  consideration.  I  place  the  patient  on  a 
lean-meat  diet,  and  under  a  graduated  system  of  exercises. 
The  beneficial  influence  of  respiratory  exercises  and  others 

*  Cohnheiiu  has  observed  great  hypertrophy  of  the  right  heart  in 
association  with  extreme  corpulence. 


138  RESPIRATORY   EXERCISES 

calculated  to  develop  the  abdominal  muscles  cannot  be 
exaggerated. 

Flatulent  distension  of  the  stomach  and  intestines  is  a 
recognised  cause  of  breathlessness.  Such  distension  not 
only  impedes  respiration  and  interferes  with  the  action  of 
the  heart  in  the  manner  indicated,  but  causes  a  reflex  dis- 
turbance of  cardiac  action.  It  is,  indeed,  especially  in 
heart-disease  that  we  should  be  on  our  guard  against  this 
condition.  An  over-loaded  stomach  may  act  in  the  same 
■way.  In  such  cases  I  am  in  the  habit  of  giving  the  fdod  in 
a  very  concentrated  form. 

In  some  cases  it  may  be  advisable  to  feed  the  patient  for 
a  time  by  the  rectum  alone.  In  so  far  as  weakness  of  the 
abdominal  walls  predisposes  to  flatulent  distension,  exercises 
calculated  to  strengthen  these  muscles  should  be  resorted 
to  (see  p.  160).  Of  drugs,  turpentine  is  perhaps  the  most 
useful.  It  should  be  administered  per  rectum,  or  by  means 
of  a  cloth  applied  to  the  belly.  In  extreme  cases  of  disten- 
sion puncture  may  be  called  for,  or  relief  may  be  got  by 
means  of  the  rectal  tube. 

In  all  diseases  of  the  heart  and  lungs  we  should  strenu- 
ously guard  against  the  accumulation  of  fluid  in  the  peri- 
toneum. It  should  be  drawn  off  directly  any  distension  of 
the  abdomen  is  observed.  No  harm  can  result  from  the 
operation  if  skilfully  performed,  while  many  evils  may  result 
from  its  omission.  Apart  from  those  already  mentioned,  it 
is  needful  to  remember  that  in  pronounced  ascites  (and  the 
same  is  true  of  extreme  flatulent  distension)  the  blood  is 
expressed  from  the  splanchnic  veins  into  other  parts  of  the 
vascular  system,  and  the  work  of  the  heart  thus  increased. 
Further,  the  impediment  to  diaphragmatic  action  favours 
the  ascitic  accumulation,  inasmuch  as  the  diaphragm  nor- 
mally pumps  the  lymph  from  the  peritoneum  into  the 
pleurae.     Indeed,  it  has  seemed  to  me  that  ascites  is  rare 


IMPEDIMENTS  TO  THE  RESPIRATORY  MOVEMENTS    139 

when  the  diaphragm  acts  vigorously.  I  can  recall  the  case 
of  a  man  dying  from  cardiac  failure  in  whom  there  was  a 
great  accumulation  of  fluid  in  the  tissues,  considerable 
enlargement  of  the  liver,  but  no  evidence  of  ascites.  Now, 
in  this  man  the  breathing  was  almost  confined  to  the 
diaphragm,  which  was  acting  with  great  vigour. 

(</)  Unsuitable  clothing.  Any  constriction  about  the  waist 
or  compression  of  the  abdomen  tends  to  interfere  with  the 
free  play  of  the  diaphragm.  The  corset  is,  of  course,  the 
greatest  offender  in  this  respect.  Nevertheless,  it  is 
astonishing  to  what  extent  the  diaphragm  can  descend  even 
with  tightly-laced  corsets. 


CHAPTEE  XIX. 

HYPEROXYGENATION  OF  THE  BLOOD— DYSPNCEA. 

Hyperoxygenation  of  the  Blood. — In  previous  chapters  I  have 
shown  how  widespread  and  complex  are  the  effects  of  the 
respiratory  movements  on  the  organism,  and  how  profoundly 
therefore  it  may  be  influenced  by  respiratory  exercises. 
One  important  effect  of  such  exercises  has  yet  to  be  men- 
tioned— i.e.,  their  influence  upon  blood-oxygenation  and 
upon  the  elimination  of  respiration  excreta.  By  means  of 
deep  breaths  we  can  produce  a  hyperoxygenation  of  the 
blood,  and  we  can  further  the  elimination  of  CO2,  and  of 
the  solid  organic  substances  which  are  normally  given  off 
from  the  lungs,  as  well  as  of  certain  volatile  toxines,  and 
this  without  increasing  in  a  notable  degree  the  work  done 
by  the  organism.  It  is  probable  that  much  of  the  good 
derived  from  respiratory  exercises  is  referable  to  the  changes 
thus  brought  about  in  the  blood. 

That  the  brain  is  profoundly  affected  by  deep  breaths  is 
shown  by  their  tendencj'  to  cause  giddiness,  and  it  is  not  a 
little  remarkable  that  this  tendency  wears  off  in  those  who 
practise  deep  breathing  regularly,  proving  that  it  must 
produce  a  lasting  effect  upon  the  organism.  Some  of  these 
effects  have  been  studied  by  W.  Marcet,  and  I  will  now 
epitomize  his  observations. 

The  time  during  which  an  individual  can  sustain  a  volun- 
tary muscle-contraction  is  determined  by  the  endurance  of  the 


HYPEROXYGENATION  OF  THE  BLOOD — DYSPNCRA     141 

cerebral  centres  engaged  in  the  act  of  volition  rather  than 
by  that  of  the  muscles  themselves.  Directly  these  centres 
are  exhausted  the  muscle-contraction  gives  way. 

This  act  of  volition  entails  a  considerable  absorption  of 
oxygen  by  the  centres  engaged  in  it,  and  the  more  the 
quantity  of  oxygen  available  for  absorption,  the  longer  can 
the  voluntary  effort  be  made  without  exhaustion  of  these 
centres,  and  the  longer  therefore  the  possible  duration  of 
the  muscle-contraction. 

After  several  deep  breaths,  an  excess  of  oxygen  is 
absorbed  ;  an  unusually  large  quantity  is  thus  available  for 
the  centres  engaged  in  voluntary  effort,  and  it  is  then  possible 
to  continue  a  voluntary  contraction  an  unusually  long  time. 
Thus  a  given  weight  can  be  raised  a  greater  number  of 
times  after  a  succession  of  forced  breaths  than  ordinarily. 
To  quote  a  specific  instance — a  man  '  who  after  ordinary 
breathing  lifted  a  weight  of  4  lbs.  203  times  in  succession, 
after  a  rest  and  forced  breathing  for  two  minutes  lifted  the 
same  weight  the  same  height  no  fewer  than  700  times.' 

It  is  a  remarkable  fact  that  the  mere  act  of  volition — as 
when  an  individual  in  imagination  directs  his  will  towards 
lifting  a  heavy  weight,  or  running  to  catch  a  train — causes 
an  augmentation  of  respiratory  movement,  and  an  increase 
in  the  volume  of  air  breathed. 

Another  fact  of  interest  is  that  volition  can  be  fatigued 
when  exerted  in  imagination  as  well  as  in  actual  muscle- 
effort.* 

In  reference  to  the  above  observations,  I  would  observe 
that  Marcet  seems  to  have  fairly  proved  that  deep  breaths 
increase  the  power  of  sustained  cortical  action.  This  effect,  I 
would  suggest,  may  be  due  not  only  to  the  augmented  supply 
of  oxygen  to  the  brain,  but  also  to  the  increased  elimina- 

*  'The  Croonian  Lectures,'  Lecture  iii.  (W.  Marcet,  M.D.,  F.R.S.), 
Brit.  Med.  Jour.,  vol.  ii.,  1895  (p.  6). 


142  RESPIRATORY   EXERCISES 

tion  of  its  waste-products,  which  are  known  to  have  a 
paralyzing  influence  on  cell-activity,  this  increased  elimina- 
tion being  brought  about  by  an  acceleration  in  the  flow  of 
blood  and  lymph,  coupled  with  an  augmented  output  of 
poisonous  substances  from  the  respiratory  tract,  without 
that  extensive  increase  in  the  production  of  waste-products 
which  happens  when  the  deep  breaths  are  produced  by 
muscle  exercise.  But,  whatever  the  explanation,  the  fact 
remains  that  deep  breaths  increase  the  power  of  sustained 
nervous  effort,  and  it  is  perhaps  owing  to  this  that  they 
are  useful  in  cases  of  neurasthenia  and  as  a  means  to  in- 
crease will-power,  a  fact  which  I  have  myself  independently 
observed. 

Dyspnoea. — I  have  already  pointed  out  that  dyspnoea  tends 
to  cause  over-action  of  the  inspiratory  muscles,  and  thus  to 
increase  the  mean  size  of  the  chest  (see  p.  93).  This  is 
well  shown  by  a  simple  experiment  suggested  by  Wilson 
Fox :  Let  the  breath  be  held  at  the  end  of  a  moderately 
deep  inspiration,  or  let  successive  moderately  deep  inspira- 
tions be  taken  with  imperfect  expiration  :  it  will  be  found 
that  the  tendency  in  either  case  is  to  recommence  inspira- 
tion.* This  shows  that  the  need  for  a  fresh  supply  of 
oxygen  is  more  imperative  than  the  need  for  removing  the 
respiration  excreta.  The  resulting  expanded  state  of  the  lung 
benefits  by  increasing  the  respiratory  area  and  by  favouring 
the  passage  of  blood  from  the  right  to  the  left  heart. 

The  breathlessness  induced  by  muscle-activity  tends  to 
make  expiration  shorter  than  inspiration  (see  p.  93),  but  in 
the  breathlessness  of  disease,  e.g.,  in  emphysema  and 
asthma,  the  reverse  is  generally  the  case. 

Cardiac  dyspnoea  is  largely  due  to  imperfect  blood  aeration 

*  '  Diseases  of  the  Lungs,'  by  Wilson  Fox,  edited  by  Sidney  Coup- 
land,  p.  l.OB,  note. 


HYPEROXYGENATION  OF  THE  BLOOD — DYSPXCEA     143 

from  failure  in  the  circulation,  but  it  is  also  in  part  due  to 
nervous  causes.  Indeed,  Alexander  Morison  maintains  that 
the  essential  cause  of  cardiac  dyspnoea  is  '  neither  pulmonary 
congestion  nor  defective  aeration,  but  a  reflex  transmitted 
from  the  stimulated  heart  to  the  accelerant  fibres  of  the 
pneumogastric  nerve,'  an  opinion  shared  by  D.  B.  Lees.* 

I  would  call  especial  attention  to  the  breathlessness 
attending  functional  palpitation,  'flushes  of  heat,'  and 
high  arterial  tension,  as  interesting  clinical  varieties. 

Let  us  now  consider  the  vascular  phenomena  observed  in 
asi^hyxia. 

There  is  first  an  aortic  rise  of  pressure,  followed  by  a 
gradual  fall.  The  pulmonary  pressure  begins  to  rise  with 
the  aortic,  but  does  so  more  gradually,  reaching  its  maximum 
when  the  latter  is  falling.  The  pressure  in  the  left  auricle 
is  little  afiected  till  the  aortic  fall  begins,  when  it  rises  to  a 
great  height,  remaining  high  till  death. 

These  phenomena  are  interpreted  by  Bradford  and  Deant 
as  follows :  The  initial  aortic  rise  is  due  to  vaso-motor 
constriction  of  the  systemic  arteries ;  the  final  fall,  to 
paralysis  of  the  left  ventricle.  The  latter  cannot  be  due 
to  emptiness  of  the  pulmonary  veins,  since  the  pressure  in 
the  left  auricle  is  actually  increased ;  I  nor  is  the  rise  due 
to  systemic  obstruction,  for  it  occurs  after  division  of  the 
cord  below  the  fifth  dorsal  nerves.  It  is  largely  due  to  vaso- 
motor constriction  of  the  pulmonary  vessels,  for  when  the 
cord  is  divided  below  the  medulla,  thus  cutting  off  the 
vaso-motor  fibres  to  the  lungs,  the  pulmonary  pressure  only 
rises  4  mm.,  whereas    before  the  division  the  pressure  is 

*  Brit.  Med.  Jour.,  1896,  vol.  i.,  p.  661. 

f  Joitr.  Phys.,  vol.  xvi.,  Nos.  1  and  2. 

X  This  opinion  harmonizes  with  Cohnheim's,  who  attributes  the  final 
pulmonary  oedema  of  asphyxia  to  paralysis  of  the  left  ventricle,  which 
he  avers  ceases  to  beat  before  the  right.  '  The  Pathology  of  the  Circu- 
lation,' vol.  i.,  p.  528. 


144  EESPIRATORY   EXERCISES 

actually  doubled.  Bradford  and  Dean  suggest  that  this 
slight  rise  is  due  to  the  direct  action  of  the  venous  blood 
on  the  pulmonary  arterioles,  but  I  think  we  can  better 
explain  it  by  reference  to  the  cessation  of  the  respiratory 
movements,  which  normally  aid  the  pulmonary  circulation.* 
Sir  George  Johnstone  believes  that  contraction  of  the 
pulmonary  arterioles  constitutes  the  essential  vascular 
phenomenon  of  asphyxia.  To  this  he  attributes  the  en- 
gorgement of  the  right  heart  and  systemic  vems,  and  the 
emptiness  of  the  left  ventricle.  It  is  difficult  to  harmonize 
this  view  with  the  fact  pointed  out  by  Bradford  and  Dean, 
that  there  is  a  great  rise  of  pressure  in  the  pulmonary  veins 
in  dyspnoea. 

*  Bradford  and  Dean  induced  the  asphyxia  in  their  experiments  by 
causing  a  '  cessation  of  artificial  respiration  in  curarized  animals  after 
division  of  both  vagi.' — Op.  cit.,  p.  74. 


CHAPTER  XX. 

ON  THE  VARIOUS   KINDS  OF  BREATHING  EXERCISES. 

Hitherto  we  have  been  occupied  for  the  most  part  with 
theoretical  considerations.  We  now  come  to  their  practical 
application.  In  this  chapter  I  shall  describe  the  various 
exercises  which  I  have  found  useful ;  in  subsequent  ones, 
the  conditions  in  which  they  should  be  employed.  For  the 
convenience  of  the  reader  I  append  a  reference  to  previous 
chapters  treating  of  important  practical  points  :  Chapter  I. 
— Means  for  preserving  pulmonary  elasticity.  Chapter  H. 
— Method  of  testing  the  tone  of  the  abdominal  muscles. 
Chapter  V.  —  Method  of  testing  thoracic  mobility. 
Chapter  XII. — Respiration  of  condensed  and  rarefied  air. 
Chapter  XIV. — Therapeutic  aspect  of  talking,  singing,  etc. 

Preliminary  Observations. 

When  a  patient  comes  before  us,  our  first  concern  (from 
the  point  of  view  of  this  work)  is  to  discover  if  there  are  any 
impediments  to  the  free  movement  of  the  chest.  The  most 
common  are  unsuitable  clothing  (e.g.,  very  tight  corsets) 
and  obesity,  and  it  may  need  considerable  perseverance  to 
remove  either  of  these.  It  should  be  remembered  that 
they  are  both  essentially  removable,  and  that  failure  to 
obtain  their  removal  will  generally  mean  failure  in  our 
patience  and  tact.     In  regard  to  tight-lacing,  it  is  well  not 

10 


146  RESPIRATORY   EXERCISES 

to  demand  too  much  at  once ;  we  must  be  content  to  gain 
our  end  little  by  little. 

It  is  important  that  the  air  which  enters  the  lungs  during 
the  breathing  exercises  should  be  as  pure  as  possible,  more 
especially  since  in  deep  breaths  (which  these  exercises 
frequently  demand)  any  impurities  that  may  be  inhaled 
will  be  drawn  deeply  into  the  lungs.  Nature  makes  every 
effort  to  protect  the  vesicles  from  the  inhalation  of  nocuous 
matters.  In  the  first  place,  normal  breathing  takes  place 
through  the  nose,  the  ingoing  air  being  thereby  warmed, 
moistened,  and  filtered.  Then,  again,  the  air  which  rushes 
in  with  every  inspiration,  i.e.,  the  tidal  current,  does  not 
pass  further  than  the  trachea  and  large  bronchi,  gaseous 
diffusion  taking  place  between  the  new  air  thus  introduced 
and  that  in  the  smaller  bronchi  and  alveoli.  The  tidal 
current  bemg  thus  confined  to  the  trachea  and  larger 
bronchi,  solid  particles  are  largely  prevented  from  passing 
into  the  smaller  air-passages,  inasmuch  as  they  do  not 
come  under  the  law  of  gaseous  diffusion.  Hence  those 
which  do  not  pass  out  in  the  expiratory  current  are 
deposited  in  the  mucous  membrane  of  the  larger  passages, 
and  becoming  entangled  in  the  mucous  secretion  which 
they  excite,  are  for  the  most  part  removed  by  expectora- 
tion. This  removal  is  further  favoured  by  the  cilife  lining 
the  entire  bronchial  tree  down  to  the  ultimate  bronchioles. 
These  lash  outwards,  and  thus  act  as  scavengers. 

Seeing  what  an  important  part  the  nasal  passages  play  in 
preparing  the  inspired  air,  it  is  imperative  that  there  shall 
be  no  nasal  obstruction,  and  therefore  every  patient  should 
be  carefully  examined  for  this  very  common  condition. 

I  have  said  that  the  air  inhaled  should  be  as  pure  as 
possible.  It  is,  unfortunately,  not  always  easy  to  secure 
pure  air,  especially  in  the  dwellings  in  large  towns.  The 
room  should  contain  a  minimum  of  furniture,  and  should 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     147 

be  well  ventilated.  In  many  cases  the  exercises  may  be 
done  with  advantage  before  the  open  window. 

If  the  patient  has  a  delicate  chest,  it  may  be  advisable 
to  dry,  purify  and  medicate  the  air.  This  may  be  done  by 
Hartnett's  antiseptic  dry-air  exhaler,  '  so  constructed  that 
it  dries  and  filters  the  air,  and  impregnates  it  with  volatile 
medicaments  which  impart  to  the  air  oxidizing  and  anti- 
septic properties  equal  to,  if  not  exceeding,  those  to  be 
found  in  pine  and  eucalyptus  forests.'  The  substances  to 
be  employed  are  eucalyptol,  menthol,  pinol,  guaiacol, 
sanitas  oil,  terebene,  and  camphor,  all  of  which  are  freely 
volatile,  and  thus  gain  access  to  the  remotest  vesicles,  un- 
like such  substances  as  creosote  and  carbolic  acid,  which,  as 
Hartnett  points  out,  are  much  less  likely  to  travel  l^eyond 
the  large  bronchi.  There  is  another  advantage  gained  by 
employing  these  highly  volatile  substances,  viz.,  their  ready 
absorption  by  the  respiratory  tract.  Such  a  substance  as 
turpentine  is  highly  penetrating,  so  much  so  that  a  small 
amount  of  wet  paint  in  a  house  will  speedily  cause  the 
urine  of  its  inmates  to  smell  of  violets. 

When  all  impediments  to  breathing  in  the  shape  of 
unsuitable  clothmg  and  obesity  have  been  removed,  when 
the  nasal  passages  are  quite  free,  and  when  the  patient 
is  provided  with  suitable  air  in  which  to  practise  the 
exercises,  difficulties  may  j^et  exist  in  the  shape  of  a  rigid 
thorax  and  of  weak  respiratory  muscles.  The  means  of 
increasing  thoracic  mobility  are  considered  in  Chapter  XXL 
In  order  to  strengthen  weak  respiratory  muscles  we  should 
attend  to  the  general  nutrition,  giving,  if  need  be,  cod-liver- 
oil,  malt,  iron,  arsenic,  and  so  forth,  and  seeking  to  develop 
the  respiratory  muscles  by  special  exercises.  These  muscles 
are,  of  course,  brought  into  play  in  breathing  exercises,  but 
the  larger  muscles  of  costal  respiration  may  be  more 
effectually  strengthened  by  dumb-bell  and  similar  exercises. 

10—2 


148  RESPIRATORY   EXERCISES 

The  dumb-bells  should  not  weigh  more  than  3  lbs. 
Largiader's  apparatus  supplied  by  Krohne  and  Sesemann 
will  be  found  ver}^  useful  for  the  purpose  of  developing 
the  muscles,  and  it  has  the  great  advantage  of  allowing 
the  force  employed  to  be  precisely  regulated. 

The  diaphragm  may  be  strengthened  by  being  made  to 
contract  against  resistance  in  the  shape  of  pressure  applied 
to  the  anterior  abdominal  wall.  This  may  be  obtained  by  a 
sheet  of  lead  of  varying  degrees  of  thickness,  fitted  to  the 
belly  in  the  horizontal  position  of  the  body. 

Preliminary  Exercises. 

The  patient  must  be  taught  to  obtain  complete  control 
over  his  respiratory  movements.  He  should  first  learn  to 
dissociate  costal  and  abdominal  breathing,  since  each  pro- 
duces its  own  peculiar  effects.  Thus,  in  deep  abdominal 
inspirations  the  bases  of  the  lungs  are  expanded  more  than 
the  apices,  while  intra-abdominal  tension  is  increased,  and 
the  blood  squeezed  out  of  the  abdominal  veins.  Moreover, 
the  abdomino-pelvic  viscera  are  compressed  and  dislocated, 
their  functions  being  thereby  altered,  while  lymph  is 
pumped  from  the  peritoneum  into  the  pleuras.  On  the 
other  hand,  in  a  full  costal  inspiration,  the  upper  regions 
of  the  lungs  are  more  full}^  expanded  than  by  any  other 
means,  while  intra-abdominal  tension  is  diminished,  and 
the  flow  of  blood  from  the  digestive  viscera  into  the 
splanchnic  veins,  and  from  the  kidneys,  pelvic  viscera,  and 
lower  extremities  into  the  inferior  vena  cava,  accelerated. 

Diaphragmatic  breathing  is  best  learned  in  the  supine 
position.  All  impediments  to  the  free  play  of  the  diaphragm 
being  removed,  the  individual  should  concentrate  his  atten- 
tion on  the  abdomen,  seeking  to  protrude  it  to  the  utmost 
with  every  inspiration,  and  to  keep  the  bony  thorax  fixed. 
After  a  little  practice,  complete  control  over  the  diaphragm 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     149 

in  all  postures  will  be  acquired.  In  diaphragmatic  breath- 
ing the  lower  ribs  tend  to  be  raised,  and  it  requires  some 
practice  before  one  can  contract  the  diaphragm  without 
raising  the  ribs — before,  i.e.,  pure  abdominal  breathing  can 
be  acquired. 

The  diaphragm,  after  its  contraction,  returns  to  the 
expiratory  position  under  the  united  action  of  the  pul- 
monary suction  above  and  the  positive  intra-abdominal 
pressure  below.  "When,  however,  pulmonary  suction  is 
slight,  as  in  emphysema,  or  when  the  intra-abdominal 
pressure  is  low,  as  happens  when  the  anterior  abdominal 
walls  are  lax,  the  expiratory  movement  of  the  diaphragm 
may  be  sluggish  and  limited.  In  such  cases  it  may  be 
accelerated  and  amplified  by  voluntarily  retracting  the 
belly  by  means  of  the  transversales.  It  may,  indeed,  be 
amplified  in  this  way  even  when  normal  in  range,  for  air 
can  be  expressed  from  the  lungs  by  retracting  the  belly, 
after  the  diaphragm  has  assumed  the  position  of  ordinary 
expiration.  Hence  it  is  a  good  plan  to  alternate  dia- 
phragmatic contractions  with  abdominal  retractions,  pro- 
trudmg  and  retracting  the  belly  to  the  fullest  possible 
extent.  This  constitutes  an  admirable  system  of  abdominal 
massage.  Abdominal  expiration  may  also  be  favoured  by 
pressing  upon  the  belly  in  the  various  ways  described  under 
the  passive  exercises  (pp.  157-159). 

The  augmentation  of  intra-abdominal  tension  resulting 
from  descent  of  the  diaphragm  may  be  increased  in  various 
ways — e.fj,  by  applying  a  weight  to  the  belly  in  the  supine 
position,  by  flexing  the  body  on  the  thighs  in  the  sitting 
posture,  or  by  wearing  a  broad  belt.  If  a  powerful 
abdominal  breath  be  taken  under  any  of  these  conditions, 
the  tension  in  the  abdomen  may  be  made  to  rise  consider- 
ably. 

Next  as  to  the  purely  costal  type  of  breathing.     This  may 


150  RESPIRATORY   EXERCISES 

be  practised  both  in  the  horizontal  and  upright  postures, 
the  attention  being  concentrated  on  the  ribs,  and  these 
should  be  raised  to  the  utmost,  while  every  effort  is  made 
to  keep  the  anterior  abdominal  wall  stationary.  Lower 
costal  breathing  may  then  be  practised.  It  is  somewhat 
difficult,  especially  to  the  civilized  woman,  in  whom  the 
movement  of  the  lower  ribs  is  generally  limited,  owing  to 
the  use  of  stays.  In  order  to  acquire  it,  let  the  palm  of 
each  hand  be  placed  on  the  corresponding  half  of  the  lower 
chest,  and  while  care  is  taken  not  to  raise  the  clavicles  nor 
protrude  the  belly,  an  attempt  should  be  made  to  separate 
the  hands  as  far  as  possible  by  expanding  the  lower  chest ; 
the  lower  ribs  should  then  be  depressed,  so  as  to  allow  the 
hands  to  come  as  close  together  as  possible.  It  will  be 
found  difficult  to  do  this  without  resorting,  to  some  extent, 
to  abdominal  breathing. 

The  patient  may  be  taught  to  expand  the  upper  part  of 
the  thorax  more  than  the  lower.  In  the  case  of  the  man 
this  is  a  difficult  feat,  and  I  do  not  set  great  store  by  it  as  a 
therapeutic  measure.  It  is  far  more  useful  to  be  able  to 
dissociate  the  movements  of  the  two  sides  of  the  chest,  for 
we  are  thus  enabled  to  exercise  one  lung  more  than  the 
other,  and  also  to  increase  the  mobility  of  the  chest,  notably 
of  the  chondro-sternal  joints.  Unilateral  breathing  is  less 
difficult  than  would  appear.  It  may  be  facilitated  in  the 
following  way :  One  hand  is  placed  in  the  corresponding 
axilla,  and  firm  pressure  is  made  on  the  same  side  of  the 
chest,  so  as  to  check  its  movements  as  far  as  possible.  The 
opposite  arm  is  then  gradually  raised  from  the  side  until 
the  wrist  rests  on  the  head.  While  the  movement  of  this 
arm  is  in  progress,  an  attempt  is  made  to  expand  to  the 
utmost  the  corresponding  side  of  the  thorax  at  the  same 
time  that  the  body  and  head  are  inclined  to  the  opposite 
side. 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     151 

It  need  scarcely  be  said  that  the  physician  must  himself 
acquire  perfect  facility  in  these  various  kinds  of  breath- 
ing, so  as  to  be  able  personally  to  instruct  his  patients- 
in  them. 

Having  mastered  these  elementary  types  of  breathing,, 
the  patient  is  in  a  position  to  undertake  various  kinds  of 
breathing  exercises.     These  we  may  divide  into  : 

Active  breathing  exercises. 

Active  breathing  exercises  conjoined  with  other  exercises. 

Passive  breathing  exercises. 

Exercises  for  developing  the  abdominal  muscles. 

Before  describing  them,  let  me  reiterate  the  following 
important  principles :  The  transit  of  blood  from  the  venae 
cavfe  to  the  aorta,  and  the  flow  of  lymph  into  the  thoracic 
ducts,  may  be  facilitated  (a)  by  increasing  the  mean  size  of 
the  chest,  an  end  best  effected  by  taking  deep  inspirations 
and  limiting  the  expiration  range ;  and  (h)  by  prolonging 
the  period  of  inspiration  and  shortening  the  expiratory 
period.  In  other  words,  the  flow  of  blood  and  lymph  can 
be  most  effectually  stimulated  by  taking  long  and  deep 
inspirations  (preferably  through  the  nose),  followed  by  short 
and  shallow  expirations  (preferably  through  the  mouth). 

All  expirations  with  closed  glottis  impede  the  circulation 
along  the  cavae  and  through  the  lungs,  and  hinder  the  flow 
of  lymph  into  the  thoracic  ducts.  While  performing  the 
various  exercises  recommended,  it  is  therefore  most  impor- 
tant to  keep  the  glottis  open. 

Deep  thoracic  inspirations  cause  a  lowering  of  the  intra- 
abdominal pressure,  and  thus  determine  a  flow  of  blood  to 
the  abdominal  vessels. 

On  the  other  hand,  deep  abdominal  breaths  increase 
intra-abdominal  pressure,  especially  if  pressure  be  made  on 
the  abdomen  at  the  same  time,  and  thus  tend  to  squeeze 
the  blood  out  of  the  abdominal  vessels. 


152  RESPIRATORY   EXERCISES 

Active  Breathing  Exercises. 

1.  Take  the  fullest  possible  thoracic  inspiration,*  followed 
by  an  ordinary  expiration. 

2.  Expire  to  the  utmost,  bending  the  body  somewhat 
forward,  and  then  take  an  ordinary  inspiration,  resuming 
the  vertical  position. 

3.  Take  the  fullest  possible  thoracic  inspiration,  and  then 
expire  to  the  utmost,  bending  the  body  forwards. 

4.  Take  a  deep  lower  thoracic  inspiration  followed  by  a 
deep  lower  thoracic  expiration. 

5.  Stand  with  the  legs  well  apart,  and  take  a  deep 
abdominal  inspiration,  followed  by  a  passive  expiration — 
i.e.,  one  resulting  from  recoil  merely. 

6.  Stand  with  the  legs  well  apart,  and  take  a  deep 
abdominal  inspiration,  followed  by  a  deep  abdominal 
expiration.  This  latter  is  effected  by  retracting  the  belly 
by  means  of  the  transverse  muscle-fibres  of  the  anterior 
abdominal  wall. 

7.  Take  a  deep  abdominal  inspiration,  then  a  lower 
thoracic  inspiration,  and  finally  complete  the  breath  by  a 
deep  thoracic  inspiration,  lifting  the  clavicles  to  the  utmost. 
Expire  in  the  reverse  order. 

8.  Take  a  lower  thoracic  inspiration,  and  follow  this  up 
by  a  deep  abdominal  inspiration  ;  make  a  deejD  abdominal 
expiration,  and  finally  a  deep  thoracic  expiration. 

9.  Assume  the  sitting  posture ;  fold  the  hands  on  the 
lap ;  flex  the  body  as  far  forward  as  possible.  Now  take 
the  deepest  possible  abdominal  inspiration  with  closed 
mouth,  and  then  gradually  raise  the  body,  lift  the  arms 

*  Some  authorities  assert  that  the  hfting  of  the  ribs  may  be  aided, 
and  the  intake  of  air  increased,  by  resting  the  hands  behmd,  or  on  the 
top  of,  the  head,  so  as  to  bring  the  pectoral  and  other  extraordinary 
muscles  of  inspiration  into  play,  but  I  do  not  find  this  to  be  the  case. 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     153 

over  the  head,  and  take  the  fullest  possible  thoracic  inspira- 
tion. After  this,  passively  expire — i.e.,  by  recoil  merely — 
with  open  mouth,  allowing  the  arms  to  drop  suddenly. 
Expiration  should  not  proceed  beyond  the  limit  of  ordinary 
expiration,  and  should  not  occupy  more  than  one  second, 
inspiration  occupying  not  more  than  six.* 

10.  This  exercise  is  recommended  by  Dr.  Ed.  Blake  for 
expanding  the  chest :  '  The  patient  is  requested,  while 
standing  erect,  to  blow  out  quickly  through  a  small  opening 
produced  by  the  pursing  of  the  lips.  At  the  same  time  he 
bends  the  head,  and  then  the  dorsal  portion  of  the  spine, 
whilst  with  his  outspread  fingers  he  compresses  the  sides 
of  the  thorax.  Having  done  this,  the  fingers  are  enlaced 
behmd  the  neck,  the  mouth  is  closed,  and  a  very,  very 
slow  and  prolonged  inspiration  taken  through  the  nostrils, 
whilst  at  the  same  time  the  spine  is  slowly  extended.  The 
object  in  placing  the  hands  behind  the  neck  is  to  bring  into 
play  all  the  muscles  of  extraordinary  inspiration.  .  .  .  The 
breath  should  not  be  held  unless  the  ventricles  are  too 
vigorous.'! 

The  subjoined  breathing  exercises  were  employed  by  the 
late  Surgeon-Captain  Hoper-Dixon  '  for  developing  the 
chest  and  otherwise  strengthening  the  body.'t  They  are 
chiefly  designed  to  educate  the  diaphragm,  constituting, 
in  fact,  a  species  of  diaphragmatic  drill. 

*  During  the  first  stage  of  this  exercise  the  abdomino-pelvic  \ascera 
are  firmly  compressed,  the  outflow  from  the  femoral  veins  is  duiiinished, 
and  the  blood  is  squeezed  from  the  intra-abdominal  veins  into  the  right 
heart,  and  also  sucked  in  the  same  direction.  During  the  phase  of 
thoracic  inspiration,  blood  is  aspirated  mto  the  abdomino-pelvic  cavity, 
and  from  the  latter  into  the  right  heart  and  lungs. 

t  '  Lip  Chorea  and  Paresis  of  External  Pterygoids '  [Stammering]. 
Bale,  1890. 

X  '  The  Art  of  Breathing,'  etc.,  pp.  22-24.  London :  Gale  and 
Polden. 


154  RESPIRATORY    EXERCISES 

1.  Eecumbent  position,  head  slightly  raised,  arms  close 
to  the  side ;  gentle  abdominal  and  lower  costal  breathing  is 
emploj'ed,  the  abdomen  being  covered  with  some  plastic 
material  accurately  fitted,  the  total  weight  not  exceeding 
31  lbs. 

2,  3.  The  same  sitting  and  standing  respectively,  without 
the  weights. 

4.  Eecumbent  position ;  a  deep  abdominal  and  lower 
costal  breath  is  taken — the  abdomen  being  weighted — and 
the  breath  held  in  full  inspiration,  after  which  a  sudden 
forcible  expiration  is  made. 

5,6.  The  same  sitting  and  standing  respectively,  without 
the  weights. 

7.  Eecumbent  position.  The  same  as  No.  4,  the  first 
four  to  eight  letters  of  the  alphabet  being  repeated  while 
the  breath  is  held. 

8,  9.  The  same  sitting  and  standing,  without  the  addition 
of  weights. 

10.  Eecumbent  position.  A  deep  lower  costo-abdominal 
inspiration  is  taken  at  the  same  time  that  a  dumb-bell  is 
raised  from  each  side  over  the  head  ;  inspiration  is  then 
completed,  and  followed  by  a  forcible  expiration,  the  dumb- 
bells being  then  returned  to  their  original  position. 

11.  The  same  practised  on  a  form;  the  head  should  be 
well  raised. 

12.  Eecumbent  position.  A  slow  lower  costo-abdominal 
inspiration  is  taken  through  the  nose,  followed  by  a  similar 
expiration  through  the  mouth.  The  exit  of  air  should  be 
80  gradual  as  not  to  warm  a  finger  held  close  to  the  mouth. 

13.  Inspiration  as  in  the  last,  followed  by  a  forcible 
expiration. 

14.  The  reverse  of  the  last,  inspiration  being  hurried  and 
expiration  slow. 

15.  A  series  of  light  respirations  are  taken  at  the  rate  of 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     1 55 

about  360  to  the  minute  in  the  recumbent,  sitting,  and 
standing  positions. 

IG.  Hurried  respirations  are  taken  for  about  five  seconds, 
after  which  a  deep  breath,  followed  by  a  gradual  expira- 
tion. 

Breathing  Exercises  conjoined  with  Active  Exercises. 

Breathing  exercises  may  be  conjoined  with  various  active 
exercises.  In  this  way  groups  of  muscles  may  be 
strengthened  at  the  same  time  that  the  patient  derives 
the  special  advantages  resulting  from  enhanced  respiratory 
activity,  which  is  in  considerable  excess  of  what  the  exer- 
cises themselves  would  induce.  By  these  means  the  circu- 
lation is  doubly  stimulated,  for  not  only  is  the  heart  excited 
to  increased  activity,  but  the  transfer  of  blood  from  the 
systemic  veins  through  the  lungs  mto  the  systemic  arteries 
is  facilitated,  the  blood  meanwhile  bemg  kept  in  a  high 
state  of  oxygenation,  and  with  a  low  percentage  of  CO2. 
The  flow  of  lymph  is  likewise  doubly  stimulated,  being 
afifected  by  both  the  exercises.  A  further  advantage  of  this 
combination  lies  in  the  fact  that  the  muscle-exercises  may 
actually  aid  the  respiratory  movements,  and  conduce  to 
increased  amplitude  of  breathing. 

In  all  the  following  exercises  the  patient  stands.  Inspira- 
tion should  be  taken  through  the  nose,  expiration  through 
the  open  mouth.  The  former,  with  its  accompanying  move- 
ment, should  l)e  long,  the  latter  and  its  movement  short. 
All  the  exercises  except  No.  7  may  be  performed  with  dumb- 
bells of  from  1  lb.  to  3  lbs. 

1.  The  arms,  held  stiff,  are  swung  round  as  far  as  possible 
in  the  sagittal  direction.  Inspiration  accompanies  the 
upward  movement,  expiration  the  downward. 

2.  The  arms,  held  stiff,  are  moved  from  the  side  of  the 
body  outwards  in  a  lateral  plane  to  the  vertical,  and  then 


156"  RESPIRATORY   EXERCISES 

returned  to  the  original  position.     Inspiration  accompanies 
the  upward  movement,  expiration  the  downward. 

3.  The  same  as  the  last,  except  that  the  arms  move  for- 
ward in  the  sagittal  plane. 

4.  The  arms  are  flexed  at  the  elbows,  and  held  close  to 
the  sides.  They  are  moved  upwards,  and  extended  to  the 
vertical  with  inspiration,  being  returned  to  the  original 
position  with  expiration. 

5.  The  arms  hanging  down  by  the  side  of  the  body,  the 
hands  are  moved  upwards  into  the  axillae  as  far  as  they  will 
go,  the  elbows  moving  outwards  in  the  lateral  plane  ;  they 
are  then  returned  to  the  original  position.  Inspiration 
accompanies  the  former  movement,  expiration  the  latter. 

6.  The  arms,  held  horizontally  in  front  of  the  body  in  the 
sagittal  plane,  are  swung  backwards  in  the  horizontal  plane 
as  far  as  they  will  go,  and  then  returned  to  the  original 
position.  Inspiration  accompanies  the  former  movement, 
expiration  the  latter. 

7.  While  the  hands  rest  upon  the  hips,  with  the  thumbs 
behind  and  the  fingers  in  front,  the  elbows  are  moved  back- 
wards as  far  as  they  will  go,  and  are  then  returned  to  the 
original  position.  Inspiration  accompanies  the  former 
movement,  expiration  the  latter. 

8.  The  arms,  held  horizontally  in  the  sagittal  plane,  are 
moved  downwards  and  backwards  in  this  same  plane  as  far 
as  they  will  go,  the  body  meanwhile  bending  forwards,  the 
original  position  being  then  resumed.  Expiration  accom- 
panies the  former  movement,  inspiration  the  latter. 

9.  The  arms  are  made  to  swing  in  the  lateral  plane,  and 
in  the  same  direction,  so  as  to  reach  the  highest  possible 
point  on  either  side,  and  are  then  returned  to  the  original 
position.  Inspiration  is  taken  with  the  ascending  move- 
ment, expiration  with  the  descending. 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     157 

Passive  Respiratory  Exercises. 

Passive  respiratory  exercises  are  adapted  to  increase  the 
expiratory  range.  They  are  therefore  especially  useful  when 
the  chest  is  permanently  fixed  in  the  inspiratory  position, 
and  when  it  is  desirable  to  get  rid  of  as  much  of  the  residual 
air  as  possible,  the  inspiratory  input  being  thus  increased. 
I  find  it  generally  much  more  difficult  to  get  my  patients  to 
breathe  out  than  to  breathe  in  properly. 

The  patient  should  lie  supine  on  a  form  or  narrow  couch. 
If  neither  of  these  is  available,  a  table  or  bed  should  be 
substituted. 

1.  The  operator  stands  behind  the  patient's  head,  which 
should  project  slightly  beyond  the  couch;  the  upper  arms 
are  then  grasped  by  the  assistant,  his  thumbs  looking 
upwards  ;  the  arms  are  then  brought  above  the  head,  so 
as  to  form  a  Y  wdth  the  body,  and  strong  traction  made 
upon  them,  the  patient  meanwhile  taking  a  deep  inspira- 
tion. They  are  then  brought  towards  the  thorax,  and  firmly 
pressed  against  it,  while  the  patient  takes  a  deep  expiration. 

2.  The  operator  stands  at  the  side  of  the  patient,  and 
grasps  the  arms  as  they  rest  at  each  side  of  the  body,  just 
above  the  elbows,  his  thumbs  being  uppermost,  and  look- 
ing towards  the  patient.  He  then  moves  the  limbs  in  a 
horizontal  plane  until  the  hands  meet  beyond  the  head  of 
the  patient,  who  meanwhile  takes  a  deep  inspiration.  This 
is  followed  by  a  deep  expiation,  while  the  limbs  are  moved 
back  to  their  original  position,  the  elbows  being  firmly 
pressed  against  the  sides. 

3.  The  patient's  upper  arms  are  held  parallel  with  the 
body,  the  forearms  crossing  over  the  chest.  The  assistant 
stands  on  a  level  with  the  patient's  hips,  and,  graspmg  the 
arms  just  below  the  elbow  (his  thumbs  looking  towards  the 
ulnar  bones),  raises  them  in  this  crossed  position  beyond 
the   head   of   the   patient,   who  meanwhile   takes   a   deej) 


158  RESPIRATORY   EXERCISES 

inspiration.  A  deep  expiration  follows,  the  arms  being 
returned  to  the  original  position,  the  assistant  making  firm 
pressure  on  the  thorax.  In  this  exercise  the  arms  can  be 
returned  to,  and  pressure  made  upon,  {a)  the  upper  part  of 
the  sternum,  {h)  the  lower  part  of  the  sternum,  (c)  the 
epigastrium,  according  as  we  wish  to  increase  expiration  in 
one  or  the  other  region. 

4.  The  arms  are  held  supine,  at  right  angles  to  the  body, 
and  are  allowed  to  fall  backwards.  The  assistant  stands  on 
a  level  with  the  patient's  lower  thorax,  and,  grasping  the 
limbs  above  the  wrist  (his  thumbs  being  upwards,  and  look- 
ing toward  the  patient's  head),  presses  them  back  as  far  as 
they  will  go  without  causing  pain,  the  patient  deeply 
inspiring  the  while.  They  are  then  brought  in  a  folded 
position  across  the  upper  sternum,  lower  sternum,  or  epi- 
gastrium, against  which  firm  pressure  is  made,  while  the 
patient  takes  a  deep  expiration. 

5.  The  assistant  rests  the  palms  of  his  hands  on  either 
side  of  the  lower  sternum,  the  fingers  pointing  towards  the 
axillae  ;  he  then  bears  his  weight  upon  the  patient  with 
every  expiration,  the  degree  of  pressure  being  regulated  by 
the  needs  of  the  case.  If  considerable  pressure  be  desirable 
he  may  bear  his  whole  weight. 

6.  The  thorax  may  also  be  compressed  by  means  of  a 
broad  belt  or  stays,  which  can  be  tightened  up  with  every 
expiration.  External  compression  of  the  lower  chest,  how- 
ever, is  not  often  required  in  the  woman  ;  the  lower  chest 
generally  gets  too  much  of  it  in  her  case. 

7.  The  operator  stands  at  the  side  of  the  patient,  level 
with  the  abdomen,  and,  resting  the  palms  of  the  hands 
across  the  belly,  makes  firm  pressure  upon  it  with  every 
abdominal  expiration. 

8.  The  patient  lies  on  one  side,  with  the  arms  held  above 
the  head,   and  the  operator,  standing  behind,  places  the 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     159 

palm  of  each  hand  over  the  uppermost  part  of  the  thorax, 
so  that  the  roots  of  the  fingers  correspond  with  the  axillary 
line,  the  thiimhs  pointing  towards  the  spine.  The  side  of 
the  thorax  is  thus  grasped  between  the  fingers  and  thumbs. 
With  every  expiration  the  operator  makes  firm  pressure  on 
the  thorax,  and  endeavours  to  make  the  fingers  and  thumbs 
meet. 

The  same  with  the  patient  lying  on  the  other  side. 

9.  The  patient  assumes  the  same  position  as  in  8.  The 
assistant  places  his  hands  longitudinally  to  the  patient,  one 
in  front  of,  and  the  other  behind,  the  upper  half  of  the 
thorax,  the  fingers  pointing  towards  the  head.  With  every 
expiration  firm  pressure  is  made,  so  as  to  bring  the  hands 
nearer  to  one  another. 

The  same  with  the  patient  lying  on  the  other  side. 

10.  Position  as  in  8.  The  assistant  places  one  hand 
across  the  belly,  and  the  other  across  the  back,  firm 
pressure  being  made  with  every  abdominal  expiration. 

11.  Position  as  in  8.  The  assistant  places  one  hand  on 
the  uppermost  side  of  the  lower  thorax,  the  fingers  pointing 
towards  the  sternum  and  the  thumb  towards  the  spine. 
The  other  hand  is  placed  on  the  uppermost  shoulder,  the 
fingers  resting  on  the  clavicle  and  the  thumb  on  the 
scapula.  With  every  expiration  the  one  hand  presses 
against  the  lower  thorax,  while  the  other  firmly  presses 
the  shoulder  down,  each  hand  squeezing  the  chest  between 
the  fingers  and  thumbs  as  much  as  possible. 

The  same  with  the  other  side. 

12.  Another  means  of  increasing  the  expiratory  range  is 
to  apply  pressure  on  the  shoulders  with  every  expiration, 
the  patient  sittmg.* 

*  Otto  L.  Hoist  employs  exercises  for  developing  the  thoracic 
muscles  and  the  kmgs  in  phthisis.  I  have  found  some  of  these  of  un- 
doubted benefit.  ('  A  Contribution  to  the  Rational  Treatment  of  Phthisis,' 
etc.,  St.  Bart.'s  Hosjntal  Journal,  September,  1896,  p.  187.) 


160  RESPIRATORY    EXERCISES 

Exercises  for  developing  the  Abdominal  Muscles. 

When  the  abdominal  "wall  is  very  flabby,  we  may  begin 
treatment  by  a  course  of  massage  and  electricity.  The 
muscles  should  be  rubbed  and  kneaded  for  half  an  hour, 
and  gently  faradized  for  fifteen  minutes,  both  operations 
being  repeated  twice  daily.  "When  they  have  by  these 
means,  sufficiently  recovered  tone,  we  may  commence  a 
series  of  graduated  exercises.  These  should  be  begun  very 
tentatively,  their  duration  and  number  being  regulated  by 
the  age  and  strength  of  the  patient. 

The  following  will  be  found  to  strengthen  the  transversales : 

1.  Firmly  retract  the  belly,  and  gradually  increase  the 
duration  of  the  retraction  from  a  few  seconds  to  one 
mmute,  or  even  longer.  It  is  not  ad^dsable  that  the 
period  of  retraction  should  in  the  first  instance  last  longer 
than  a  few  seconds,  especially  in  the  case  of  a  very  weak 
patient. 

2.  Repeatedly  retract  the  belly  at  the  rate  of  from 
ten  to  sixty  retractions  per  minute,  keeping  the  ribs  fixed. 
A  deep  abdominal  breath  should  alternate  with  each  re- 
traction. 

3.  Firmly  retract  the  bellj',  and  then,  while  the  retraction 
is  kept  up,  inspire  and  expire  to  the  fullest  extent.  Time 
from  ten  to  sixty  seconds. 

4.  Take  the  deepest  possible  lower  costo-abdominal  in- 
spiration by  means  of  the  abdomen  and  lower  ribs.  Close 
the  glottis ;  then  repeatedly  retract  and  protrude  the  belly 
by  alternately  contracting  the  transversales  and  the  dia- 
phragm. (This  is  an  advanced  exercise,  and  can  seldom 
be  advantageously  employed  for  more  than  thirty  seconds.) 

5.  Alternately  expand  and  contract  the  costal  arch  to  the 
fullest  extent.  The  upper  portion  of  the  transversales  is 
thereby  exercised. 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     161 

All  these  exercises  should  be  performed  in  the  standing, 
sitting,  and  lying  postures  in  turn. 

The  subjoined  exercises  act  more  generally  on  the  anterior 
abdominal  muscles : 

6.  A  complete  expiration  is  taken  from  the  position  of 
ordinary  inspiration. 

7.  The  patient  stands  with  his  legs  two  or  three  feet 
apart,  and,  the  knees  being  kept  fixed,  the  trunk  is  moved 
forwards  as  far  as  possible  and  then  brought  back  to  the 
vertical. 

8.  The  patient  stands  with  his  legs  apart,  and  flexes  the 
trunk  as  far  as  possible,  first  on  one  side  and  then  on  the 
other. 

9.  The  patient  stands,  and  the  body  is  bent  backwards, 
the  knees  being  at  the  same  time  gradually  bent  and  the 
arms  slowly  extended  over  the  head,  and  then  separated. 
After  the  body  has  been  bent  backwards  as  far  as  possible 
without  upsetting  the  equilibrium,  it  is  gradually  brought 
back  to  the  vertical  position. 

10.  The  patient  sits  on  a  low  stool,  and  bends  his  body 
alternately  backwards  and  forwards,  the  forward  movement 
being  resisted  by  an  assistant,  who  grasps  the  shoulders 
from  behind. 

11.  The  patient  sits  on  a  stool  with  his  back  to  the  wall. 
On  either  side  of  him  is  a  ring  firmly  fixed  into  the  wall. 
Through  each  ring  there  passes  a  cord,  to  the  ends  of  which 
weights  are  attached.  The  portion  of  cord  between  the 
two  rings  is  passed  round  the  waist.  The  body  is  then 
repeatedly  flexed  on  the  thighs,  and  the  weights  thereby 
raised.  This  exercise  has  the  great  advantage  that  the 
work  put  upon  the  abdominal  muscles  can  be  regulated 
with  nicety  by  altering  the  weights  to  be  raised. 

12.  The  supine  position  is  assumed,  and  while  the  legs 
are  being  held  by  an  assistant,  the  body  is  gradually  moved 

11 


162  RESPIRATORY    EXERCISES 

towards  the  vertical.  If  an  assistant  is  not  available,  the 
patient  may  lie  on  the  floor,  and  place  the  feet  under  some 
resistant  object.  If  the  abdominal  muscles  are  weak,  the 
patient  Toiay  be  unable  to  attain  the  vertical,  and  in  this 
case  he  should  not  attempt  to  do  so,  but  only  lift  the  body 
so  far  as  can  be  done  without  strain.  When  beginning  this 
exercise,  the  patient  may  be  allowed  to  help  himself  with 
his  arms.  When  the  arms  are  not  used  in  this  w^ay,  it  is 
well  for  the  patient  to  make  firm  pressure  with  his  fingers 
agamst  the  inguinal  rings,  so  as  to  obviate  an  unpleasant 
sensation  which  is  often  felt  m  these  regions  during  this 
exercise,  and  to  avert  the  possibility  of  a  hernia.  In  some 
cases,  though  this  is  not  often  desirable,  one  may  mcrease  the 
weight  which  the  anterior  abdominal  muscles  have  to  lift 
by  causing  the  patient  to  hold  weights  of  varying  amounts. 
It  is  most  important  that  the  breathing  should  be  carried 
on  naturally  during  the  performance  of  these  exercises. 
It  should  be  of  the  costal  type. 

13.  When  the  abdominal  muscles  have  acquired  sufficient 
strength,  the  patient  may  repeat  Exercise  12,  sittmg  on  a 
hassock,  and  alternately  lowering  the  head  backward  until 
it  touches  the  ground,  and  assuming  the  sitting  posture. 
Or  he  may  sit  on  a  couch  or  low  table  with  his  legs  up  and 
his  buttocks  slightly  projecting  beyond  the  edge;  and  while 
the  legs  are  held  down  by  an  assistant,  the  body  is  gradually 
lowered  over  the  edge  as  far  as  it  will  go,  and  then  gradually 
brought  back  to  the  vertical.  During  this  procedure  it  is 
advisable  that  the  inguinal  rings  should  be  supported  as 
directed. 

14.  The  rope-hauling  exercise  is  a  very  valuable  means  of 
strengthening  the  abdominal  muscles.  It  may  be  performed 
indoors  in  the  following  way  :  Two  strong  elastic  cords, 
about  2  feet  in  length,  are  fixed  by  one  end  into  the  floor, 
tlieir  free  ends  being  provided  with    rings  which  can  be 


THE  VARIOUS  KINDS  OF  BREATHING  EXERCISES     163 

grasped  by  the  hands.  These  cords  are  alternately  stretched 
by  first  pulling  with  one  hand  and  then  with  the  other,  as 
in  rope-hauling. 

15.  The  hands  grasp  a  horizontal  bar  or  rings  suspended 
from  the  ceiling  ;  the  body  is  then  suspended  in  space,  and 
allowed  to  swing  backwards  and  forwards. 

Rowing,  it  may  here  be  remarked,  does  not  especially 
tend  to  develop  the  anterior  abdominal  muscles.  The 
forward  movement  certainly  is  eflfected  through  them,  but 
they  take  no  part  in  the  backward  movement,  since  the 
necessary  antagonism  to  the  dorsal  muscles  is  afforded  by 
the  resistance  of  the  oars. 

It  will  be  well  in  this  place  to  make  some  observations  on 
the  subject  of  cycling. 

One  of  the  advantages  of  cycling  is  that  it  renders  possible 
a  great  deal  of  outdoor  exercise  without  fatigue.  How  are 
we  to  explain  the  wide  difference  in  this  respect  between  it 
and  the  natural  modes  of  progression?  There  are,  I 
suggest,  two  chief  reasons  :  In  cycling  (a)  the  legs  have  not 
to  support  the  body,  and  (h)  the  vascular  column  is 
shortened,  (a)  The  legs,  having  no  work  of  support,  can 
devote  themselves  entirely  to  that  of  propulsion,  whereas  in 
walking  and  running  much  of  the  energy  expended  by  the 
muscles  of  the  lower  extremities  is  spent  in  supporting  and 
balancing  the  body.  Even  the  mere  act  of  standing  in- 
volves a  considerable  expenditure  of  muscle-energ}^  both  by 
the  leg  and  trunk  muscles ;  while  in  cycling  not  only  are  the 
leg  muscles  wholly  freed  from  the  work  of  support  and 
balance,  but  the  trunk  muscles  also  are  largely  relieved  from 
the  latter  function  if  the  proper  sitting  posture  be  assumed. 
What  do  I  mean  by  the  proper  sitting  posture  '?  If  a  person 
sits  so  as  to  ride  at  ease,  he  should  hunch  the  back  some- 

11—2 


164  KESPIRATORY   EXERCISES 

what,   since  this   involves   the   expenditure  of   much   less 
muscle-energy  than  the  bolt-upright  position.     This  is  one 
reason  why  the  back  should   be  well  arched   in  cycling. 
(h)  Man  is  distinguished  from  all  other  mammals  by  his 
erect  posture.     This,  while  securing  him  the  great  advan- 
tage of  being  free  to  devote  the  upper  extremities  to  other 
purposes  than  propulsion,  has  also  more  than  one  disadvan- 
tage.    If  an  intelligent  extra-mundane  being  were  to  see 
man  for  the  first  time  in  the  horizontal  posture,  it  would 
surely  never  occur  to  him  that  it  is  natural  for  him  to  be 
erect.     There  is  something  incongruous  in  an  animal  built 
on  the  longitudinal  plan  standing  and  progressing  upon  one 
end  of  its  long  axis.     Yet  this  is  what  man  is  and  what  he 
does,  and  it  places  him  at  a  twofold  disadvantage :  first,  in 
the  matter  of  progression,  it  leaves  him  with  but  two  legs 
to  walk  with,  and  the  muscles  of   these  two,  as   already 
observed,  have  to  expend  a  great  deal  of  their  energy  in 
balancing  the  body,  which  from  its  upright  posture  is  much 
more  difficult  to  balance  than  in  the  case  of  the  quadrupeds  ; 
secondly,  the  height  of  the  blood  column  is  increased,  the 
influence  of  gravity  on  the  circulation  being  correspond- 
ingly increased.     In   particular,   as   Leonard  Hill  has  so 
ably  shown,  there  is  a  tendency  for  the  blood  to  gravitate 
into  the  splanchnic  area  when  the  erect  posture  is  assumed, 
and  I  cannot  but  think  that  the  fatigue  of  standing  and 
walking   is  largely  due  to  this  tendency.     It  is  normally 
counteracted  by  the  contraction  of  the  splanchnic  arteries, 
by  the  pressure  of  the  firmly-contracted  abdominal  muscles 
on  the  splanchnic  veins,  and  by  the  negative  intra-thoracic 
pressure,  and  in  cycling  it  is  much  reduced,  and  for  at  least 
three  reasons  :  (1)  The  mean  distance  between  the  head  and 
feet  is  diminished,  and  here  we  have  an  additional  reason 
why  the  body  and  head  should  incline  well  forwards ;  (2)  the 
splanchnic  veins  are  compressed  by  the  rhythmic  flexions  of 


THE  VARIOUS  KINDS  OF  BREATHIXG  EXERCISES     165 

the  thighs  on  the  abdomen,  and  this  compression  is  in- 
creased by  the  forward  attitude  ;  (3)  the  aspiratory  action 
of  the  thorax  is  increased,  owing  to  its  increase  in  mean 
size,  this  occurring  in  all  active  exercises.  That  the  for- 
ward attitude  tends  to  contract  the  chest  is  an  altogether 
fallacious  notion. 


CHAPTER  XXI. 

RESPIRATORY  EXERCISES  IN  DISEASES  OF 
THE  LUNGS. 

Eespiratory  exercises  will  be  found  of  great  use  in  the 
l^revention  and  treatment  of  pulmonary  diseases.  They 
benefit  in  many  ways,  but  chiefly  by  stimulating  the  flow  of 
blood  (pulmonary  and  systemic)  through  the  lungs,  and  in 
this  and  other  ways  favouring  the  development  of  these 
organs.  They  also  benefit  by  increasing  the  mobility  of  the 
thoracic  cage.  That  they  are  capable  of  developing  the 
lungs  is  shown  by  the  increased  thoracic  girth  that  can  be 
brought  about  by  their  means.  The  way  in  which  this 
increase  is  effected  is  described  in  Chapter  lY. 

As  a  Preventative  of  Pulmonary  Disease. — The  more  per- 
fectly developed  the  lungs,  and  the  more  mobile  the  thoracic 
cage,  the  less  is  the  tendency  to  such  diseases  as  phthisis, 
Ijronchitis,  and  pneumonia.  This  is  a  well-recognised  fact. 
Nothing  is  more  certain,  for  instance,  than  that  small,  ill- 
developed  lungs  are  prone  to  tuberculosis.  The  so-called 
phthinoid  chest,  indeed,  owes  its  characteristics  to  the  small- 
ness  of  the  contained  lungs,  and  it  is  in  consequence  of 
their  smallness  that  the  thorax  assumes  the  position  of 
super-extraordinary  expiration. 

Here  let  me  observe  that  an  ill-developed  chest  is  not 
infrequently  overlooked.  Many  a  person,  who  when 
dressed  appears  to  have  a  normal  chest  development,  dis- 


RESPIRATOIIY    EXERCISES    IN    LUNG    DISEASE       107 

closes,  when  stripped  and  carefully  examined,  some  marked 
thoracic  defect.  A  common  cause  of  this  deceptive  appear- 
ance is  an  abundant  deposit  of  fat  about  the  thorax.  In 
the  tall,  slim  youth  we  easily  recognise  the  phthinoid  chest 
by  the  sloping  shoulders  and  the  small  sagittal  measure- 
ment ;  but  when  he  becomes  a  stout  man  he  may  appear^ 
on  casual  observation,  to  have  a  well-formed  chest.  In 
such  a  case  acute  pneumonia  or  bronchitis  is  always  serious,, 
although  the  apparently  good  development  of  the  chest  may 
suggest  a  favourable  prognosis. 

Not  only  do  good  pulmonary  development  and  free 
thoracic  mobility  tend  to  prevent  lung  disease,  but  they 
place  the  individual  at  an  advantage  should  he  happen  to 
develop  it,  both  on  account  of  the  high  resisting  power 
belonging  to  the  well-grown  lungs,  and  on  account  of  the 
large  margin  of  reserve  that  goes  with  them.  It  is  because 
of  the  smallness  of  this  reserve  in  those  with  ill-developed 
lungs  that  they  are  so  liable  to  succumb  when  attacked  by 
acute  pulmonary  disease,  and  it  is  very  largely  for  this 
same  reason  that  the  danger  from  it  increases  with  every 
year  after  middle  life,  the  reserve  diminishing  as  emphy- 
sema and  thoracic  rigidity  advance. 

Eespiratory  exercises  are  more  suitable  for  developing 
the  lungs  than  gymnastics,  much  of  the  increase  in  thoracic 
girth  obtained  by  the  latter  means  being  due  to  develop- 
ment of  the  thoracic  muscles,  and  not  infrequently  to 
emphysema,  induced  by  violent  effort  with  closed  glottis. 
By  means  of  respiratory  exercises  we  are  able  to  develop 
the  lungs  without  any  danger  of  producing  emphysema,  and 
without  putting  the  patient  to  the  trouble  of  bringing  about 
an  altogether  needless  hypertrophy  of  the  arm  and  chest 
muscles.  The  great  development  in  these  muscles  which 
gymnastics  tend  to  bring  about  serves  no  good  end.  It 
is  perhaps  amusing  to  see  a  professed  gymnast  walk   on 


168  RESPIRATORY    EXERCISES 

his  upper  extremities,  but  it  is  physiologically  ridiculous. 
Feats  of  strength  are  wholly  useless  from  the  physiological 
point  of  view  ;  nay,  they  may  even  be  harmful,  and  actually 
lead  to  a  diminution  in  vital  capacity. 

Respiratory  exercises  are  very  useful  in  favouring  the 
expansion  of  collapsed  lung  after  pleural  effusion.  They 
should  be  assiduously  employed  in  empysema  after  the 
external  wound  has  healed,  and  may  even  be  begun  before 
this.  They  may  also  be  of  considerable  service  to  patients 
who  are  compelled  to  remain  for  a  long  time  in  bed,  pro- 
moting as  they  do  the  general  health,  and  preventing  the 
tendency  to  hypostatic  congestion  of  the  lungs.  Take  as 
an  example  the  case  of  chronic  tubercular  disease  of  the 
hip  or  knee,  in  which  the  patient  is  compelled  to  lie  for 
weeks  or  months  on  his  back,  or,  again,  the  tedious  con- 
valescent stage  of  typhoid. 

It  is  unnecessary  to  particularize  the  class  of  bedridden 
patients  for  whom  such  exercises  are  unsuitable  ;  this  may 
safely  be  left  to  the  judgment  of  the  reader. 

In  considering  the  influence  of  respiratory  exercises  in 
warding  off  pulmonary  disease,  the  importance  of  always 
inspiring  through  the  nose  must  be  insisted  upon.  .  The 
fact  is  not  yet  properly  appreciated  that  nasal  obstruction, 
by  compelling  inspiration  through  the  mouth,  is  a  potent 
cause  both  of  bronchitis  and  phthisis.  I  have  seen  several 
instances  of  both  these  diseases  thus  induced.  In  all 
diseases  of  the  lungs  the  nasal  passages  should  be  carefully 
explored,  and  any  obstruction  immediately  removed. 

As  a  Means  of  treating  Pulmonary  Disease. — (a)  Bronchitis. 
I  have  obtained  some  good  results  in  bronchitis  from  respira- 
tory exercises.  This  is  not  surprising,  for  inflammation 
of  the  bronchi  is  favoured  by  sluggish  movement  of  the 
chest,  with  the  consequent  sluggishness  of  the  circulation 
(pulmonary  and  systemic)  through  the  lungs,  and  hence 


IN    DISEASES    UF   THE    LUNGS  169 

anything  that  accelerates  the  puhnonary  flow  is  beneficial. 
"Wherefore  it  is  of  the  utmost  importance  to  remove  every 
impediment  to  free  respiratory  movement  in  this  disease. 
I  have  already  observed  that  obesity  constitutes  such  an 
impediment,  and  that  is,  I  believe,  one  of  the  reasons  why 
bronchitis  is  so  common  in  the  obese.  Now,  respiratory 
movements  are  useful  in  reducing  obesity,  and  they  are 
therefore  clearly  indicated  for  stout  bronchitic  patients.  I 
have  seen  cases  of  chronic  bronchitis  benefit  most  remark- 
ably by  cycling,  the  result  being  doubtless  largely  due  to 
the  increased  activity  of  the  respiratory  movements. 

Otto  L.  Hoist  recommends  the  following  procedure  for 
clearing  the  air-passages  of  mucus.  The  patient  assumes 
a  semi-reclining  position,  and  an  assistant  stands  in  front 
of  him,  and  lays  both  hands  flat  upon  his  chest.  '  The 
patient  is  told  to  take  a  deep  breath,  and  during  the  expira- 
tion a  vibratory  movement  is  given  by  the  operator's  hands 
as  long  as  the  expiration  lasts,  and  a  little  longer  ;  then  the 
hands  are  moved  lower  down  on  the  chest,  and  the  same 
performance  is  gone  through  till  the  operator's  hands  have 
covered  consecutively  the  whole  surface  of  the  chest,  front 
and  back.'* 

(h)  Phthisis.  In  all  but  the  very  acute  forms  of  phthisis 
I  advocate  the  employment  of  respiratory  exercises  ;  the 
more  abundantly  the  lungs  are  flushed  with  blood,  the  more 
capable  are  they  of  resisting  the  bacillus.  We  should,  of 
course,  proceed  cautiously  if  the  tendency  to  haemoptysis  is 
great,  but  a  small  degree  of  haemorrhage  does  not  contra - 
indicate  this  treatment,  for,  as  pointed  out  by  a  writer  in 
the  Lancet,  pulmonary  haemorrhage  does  not  show  a  special 
tendency  to  follow  upon  exertion,  being,  on  the  contrary, 
comparatively  frequent  at  night  and  in  the  early  hours  of 

*  '  A  Contribution  to  the  Rational  Treatment  of  Phthisis  in  its  EarHor 
Stages,'  Otto  L.  Hoist,  St.  Bart.'s  Hospital  Journal,  September,  lb96. 


170  RESPIRATORY   EXERCISES 

the  morning.*  I  have  myself  been  asked  by  a  patient 
suffering  from  slight  haemoptysis  whether  singing  would  be 
injurious  to  him.  In  most  such  cases  we  may  not  only 
sanction,  but  should  actually  encourage  it,  provided  we  are 
sure  that  the  patient  adopts  the  proper  mode  of  breathing 
and  does  not  unduly  exert  himself.  Much  of  the  good 
effect  obtained  by  sending  patients  with  phthisis  to  cold 
mountainous  districts  is  due  to  the  increased  freedom  of 
the  respiratory  movements  which  this  entails. 

In  connection  with  breathing  exercises  i^roper,  other 
exercises,  chiefly  of  the  muscles  of  the  trunk  and  thorax, 
as  described  by  Otto  Hoist,  may  be  resorted  to.f 

Jacoby  I  employs  a  method  of  treating  phthisis  which 
may  be  referred  to  here.  Starting  upon  the  assumption 
that  the  predisposition  of  the  pulmonary  apices  to  phthisis 
results  from  the  tendency  of  the  blood  to  gravitate  away 
from  the  apices  in  the  erect  position  of  the  body,  he  seeks 
to  determine  a  flow  of  blood  to  them  by  mechanical  means. 
The  patient  is  placed  on  a  bed  with  the  shoulders  de- 
pendent, and  hot  water  (from  30°  to  45°  C.)  is  allowed  to 
play  over  the  thorax  through  a  series  of  tubes,  four  behind 
and  four  in  front,  the  whole  being  enveloped  in  an  air-tight 
gutta-percha  vest.  The  patient  then  gets  up,  and,  after 
being  dried,  his  shoulders  are  wrapped  in  a  moist  bandage  ; 
thereupon  the  recumbent  posture  is  assumed  for  two  to 
three  hours,  the  legs  and  abdomen  being  elevated  above  the 
chest.     This  routine  is  performed  twice  daily. 

(c)  Spasmodic  asthma.  The  effect  of  respiratory  exercises 
in  this  disease  is  often  little  short  of  miraculous.  The 
following  is  an  instance  : 

F.,  Hit.  21.  Both  parents  highly  neurotic  ;  not  menstruated  for  eipfht 
months.    During  the  last  six  years  has  been  subject  to  stuffy  breathing 

*  Lancet,  1895,  vol.  ii.,  p.  535.  t  Oj;ms  cit. 

X  Milncli.  mod.  WorhcnxrJiri.ft,  1H97,  Nos.  7  and  8. 


IN    DISEASFS    OF   THE    LUNGS  171 

at  night,  and  to  attacks  of  spasmodic  asthma.  Is  very  irritable,  in- 
chncd  to  cry,  suffers  from  flushes,  giddiness,  and  other  symptoms  in- 
cidental to  menstrual  suppression.  "Wears  Jaeger's  stays,  and  although 
these  are  what  most  women  would  describe  as  '  quite  loose,'  they 
prevent  fi'cc  expansion  of  the  lower  costal  chest,  which  is  much 
narrower  than  the  upper  part.  Sleeps  with  the  ^\'indow  shut  in  a 
bedroom  overcrowded  with  furniture. 

Treatment. — Mag.  sulph.,  sod.  sulph.,  aa  5i.,  in  warm  water  every 
morning.  Excess  of  furniture  to  be  removed  fi'om  bedroom,  and 
window  to  be  kept  open  all  night.  To  sleep  with  the  mouth  shut. 
Respiratory  exercises  for  half  an  hour  twice  daily. 

The  effect  of  this  treatment  was  very  marked.  Men- 
struation came  on  very  soon.  Every  unpleasant  symptom 
disappeared,  and  there  has  been  no  return  of  the  asthma. 

Marcet  has  noticed  the  beneficial  influence  of  deep 
breaths  in  asthma.  He  refers  to  the  case  of  a  physician 
in  whom,  '  at  2.30  a.m.,  loud  wheezing  and  tightness  of  the 
chest  came  on,  when  a  succession  of  forced  inspirations  had 
the  immediate  effect  of  arresting  both  the  wheezing  and  the 
tightness ;  a  second  attack  the  same  night  was  averted  in  a 
similar  manner.'  *  He  also  mentions  a  case  in  which  the 
tendency  to  asthmatic  seizures  was  greatly  reduced  by 
cj'cling,  and  he  attributes  the  good  effect  in  both  these 
cases  to  the  extra  supply  of  oxygen,  brought  about  by  the 
heightened  activity  of  the  respiratory  movements.  A  de- 
ficiency of  oxygen  in  the  blood  he  regards  as  an  important 
factor  in  the  causation  of  asthma. 

Metcalfe  has  obtained  good  results  in  asthma  from 
massage  of  the  chest  muscles. 

Chronic  bronchitis,  phthisis,  and  spasmodic  asthma 
have  all  been  markedly  benefited  by  treatment  in  the 
compressed-air  chamber ;  also  by  inspiring  compressed,  and 
expiring  mto  rarefied,  air.  By  both  these  means  dyspnoea 
can  be  relieved  in  a  remarkable  way,  and  it  is  surprising 

*  Lancet,  1895,  vol.  ii.,  p.  78. 


172  RESPIRATORY   EXERCISES 

that  so  valuable  a  therapeutic  agent  should  have  been  so 
entirely  neglected  in  this  country. 

(d)  The  absorption  of  pleural  effusions  may  be  aided  by 
means  of  respiratory  exercises.  It  has  been  experimentally 
shown  that  if  fluid  be  injected  into  the  pleura  its  absorption 
is  hastened  by  artificial  respiration.  It  is,  however,  only  in 
the  chronic  forms  of  effusion  that  breathing  exercises  are 
called  for.  They  are  not  practicable  in  the  acute  forms  with 
fever.  Indeed,  in  such  cases  the  opposite  plan  of  bandaging, 
and  thus  fixing  the  affected  side,  has  been  practised. 

(e)  Emphysema.  The  treatment  of  emphysema  by 
respiratory  exercises  opens  up  so  many  questions  of 
interest  that  I  propose  to  devote  a  separate  chapter  to 
the  subject. 

This  is  a  convenient  place  for  referring  to  tlie  means  of 
increasing  the  mobility  of  the  thoracic  cage. 

All  exercises  in  costal  breathing  tend  to  increase  the 
mobility  of  the  cage,  and  the  younger  the  subject,  the  more 
potent  are  they  to  do  this.  They  should,  however,  not  be 
violent,  seeing  that  great  muscle  -  development  tends  to 
increase  the  rigidity  of  the  thoracic  bones  (see  p.  34).  It 
may  not  be  practicable  to  prevent  a  man  from  following  a 
laborious  calling,  but  we  can  at  least  forbid  gymnastics 
and  all  athletic  pursuits  which  tend  to  induce  undue 
muscularity.  Similarly,  all  exercises  which  cause  marked 
dyspncea  should  be  avoided,  inasmuch  as  this  conduces  to 
fixity  of  the  cage  by  bringing  about  contracture  of  the 
costal  elevators. 

On  the  other  hand,  the  sedentary  and  those  with  feeble 
muscle-systems  should  be  encouraged  to  lead  a  muscularly 
active  life,  and  special  means,  in  the  shape  of  dumb-bell 
and  other  exercises,  should  be  resorted  to  in  order  to 
develop  the  muscles  and  to  increase  the  amplitude  of 
respiratory  movement.     It  is  among  such  that  we  can  do 


IN    DISEASES   OF   THE   LUNGS  173 

most  good,  especially  if  the  lungs  are  healthy.  When  the 
chest  has  become  fixed  from  old  age  or  chronic  emphysema, 
our  efforts  are  less  successful. 

A  useful  means  of  increasing  thoracic  mobility  is  the 
inhalation  of  compressed  air  and  the  breathing  into 
rarefied  air. 

In   seeking  to  increase  thoracic  mobility,   we  must  be 
careful  to  observe  the  position  in  which  the  chest  is  fixed. 
If,  for  instance,  we  are  dealing  with  a  small  phthinoid  chest 
in  which  the  mean  position  is  that  of  super-extraordinary 
expiration,  our  efforts  should  be  directed  to  increasing  the 
inspiratory  range,  and  similarly  in  regard  to  the  contracted 
lower  thorax  in  women  who  wear   stays.      Here  we  give 
exercises  for  increasing  the  inspiratory  range  of  this  part 
of  the  chest.     When,  however,  the  thorax  is  fixed  in  the 
position  of   super  -  extraordinary  inspiration,   as   in   large- 
lunged  emphysema,  our  chief   aim  should  be  to  increase 
the  expiratory  range,  and  a  patient  should  be  put  through 
a  systematic  course  of   expiratory  exercises.     This  is  not 
only  useful  in  increasing  the  mobility  of  the  thoracic  joints, 
but  in  counteracting  the  contracture  of  the  costal  elevators. 
For  if  this  contracture  is  due,  as  I  suggest,  to  overaction  of 
these  muscles,  which  are  thus  not  properly  antagonized  by 
the   costal   depressors   (notably   by   the    great    abdominal 
muscles),  it  follows  that  we  should  seek  to  bring  about 
the  normal  antagonism.     We  cannot,  as  in  talipes,  divide 
the  contractured  muscles. 

In  the  latter  class  of  cases  some  help  may  l)e  got  from 
pressure  applied  externally  to  the  chest.  Thus,  the  patient 
may  forcibly  compress  the  sides  of  the  chest  during  expira- 
tion by  resting  the  palms  of  the  hands  on  the  lower  part  just 
in  front  of  the  axillary  line,  the  fingers  pointing  forwards. 


CHAPTEE  XXII. 

RESPIRATORY  EXERCISES  IN  EMPHYSEMA. 

In  order  to  understand  the  treatment  of  emphysema  by 
means  of  respiratory  exercises,  it  will  be  needful  to  consider 
the  mechanism  of  thoracic  expansion  in  hypertrophous  em- 
physema. 

In  a  typical  instance  of  large  -  lunged  emphysema  the 
thorax  is  permanently  enlarged,  being  in  a  condition  of 
super-extraordinary  inspiration  ;  in  other  words,  the  mean 
size  of  the  chest  is  greater  than,  were  the  lungs  normal,  it 
would  be  after  the  fullest  possible  inspiration,  and,  further- 
more, the  entire  thorax  is  permanently  elevated.  Thus,  the 
clavicles  are  raised,  their  anterior  ends  being  carried 
forwards  and  their  curvatures  exaggerated ;  the  sternum  is 
moved  forwards  and  upwards,  its  anterior  aspect  being 
markedly  convex  from  above  downwards,  the  manubrium 
and  gladiolus  forming  the  so-called  angulus  Ludovici ;  the 
dorsal  spine  is  similarly  carried  backwards,  and  is  convex 
posteriorly ;  the  ribs  are  more  horizontal  than  normally, 
and  their  curves  more  opened  out ;  the  costal  arch  is 
abnormally  wide,  and  the  diaphragm  flattened. 

How  is  this  great  expansion  of  the  chest  to  be  accounted 
for  ?*    One  is  apt  to  assume  that  it  is  secondary  to  enlarge- 

*  It  is  remarkable  how  little  attention  has  been  given  to  this  subject 
by  physicians.  Neither  Hilton  Faggc  nor  Bristowe  even  refer  to  it 
in  their  text-books ;  and  how  vague  are  the  ideas  prevailing  on  it  is 


RESPIRATOKY    EXERCISES    IX    EMPHYSEMA       175 

ment  of  the  lungs,  and  that  the  latter  actually  thrust  the 
chest- walls  outwards  ;  but  this  explanation  a  little  reflection 
shows  to  be  wrong,  seeing  that  the  lungs  exercise  suction 
upon  the  thorax.  It  is  true  that  this  suction  is  diminished 
in  emphysema,  owing  to  diminution  in  pulmonary  elasticity, 
but  except  possibly  in  very  advanced  cases,  when  'the  lungs 
may  even  appear  to  project  on  opening  the  thorax '  after 
death  (Wilson  Fox),  they  retain  some  degree  of  elasticity, 
and  must  therefore  habitually  exercise  some  suction,  how- 
ever slight,  upon  the  chest-walls. 

Another  view,  that  of  Freund,  assigns  the  chest-expansion 
to  overgrowth  of  the  ribs  and  sternum,  whereby  they  are 
altered  in  shape  and  position  ;  but  such  overgrowth,  there 
can  be  little  doubt,  takes  place  in  consequence  of  thoracic 
expansion,  and  is  not  the  cause  of  it. 

In  Chapter  lY.  I  have  dealt  with  the  factors  which 
determine  the  size  of  the  chest,  and  have  prepared  the 
way  for  an  explanation  of  its  progressive  enlargement  in 
hypertrophous  emphysema.  The  two  essential  factors  con- 
tributing to  this  enlargement  are  defective  pulmonary 
elasticity  and  dyspnoea.  In  consequence  of  the  former, 
pulmonary  suction  is  diminished,  and  the  thoracic  elevators, 
being  no  longer  properly  antagonized,  gain  the  ascendency 
and  expand  the  chest,  which  may  thus  go  on  enlarging  for 
many  years  before  any  decided  symptoms  develop,  and 
before  the  individual  has  any  notion  of  his  lungs  not  being 
perfectly  normal.  Sooner  or  later,  however,  dyspncea 
develops,  and  inasmuch  as  this  excites  the  inspiratory, 
more  than  the  expiratory,  muscles,  there  is  now  a  still 
greater  preponderance  of  the  expanding  forces.  This  pro- 
tracted overaction  of  the  thoracic  elevators  gradually  leads 

sufficiently  attested  by  the  following  (juotation  from  the  article  on 
'  Emphysema  '  in  Quain's  '  Dictionary  of  Medicine  ':  '  The  lungs  being 
the  seat  of  general  expansion,  the  thorax  is  kept  abnormally  distended.' 


176  RESPIRATORY    EXERCISES 

to  their  hypertrophj^  and  shortening,  in  consequence  of 
which  the  thorax  gets  fixed  in  the  expanded  position,  the 
fixation  being  also  favoured  by  changes  in  the  thoracic 
bones  and  joints.  The  expiratory  muscles  are  also  brought 
into  forcible  play.  Thus,  the  abdominal  muscles  are  tense, 
and  the  powerful  contraction  of  the  transversales  may  give 
rise  to  one  or  two  grooves  in  them.  This  of  course  tends 
to  retard  the  process  of  expansion,  but  does  not  prevent  it, 
because  the  inspiratory  muscles  act  still  more  powerfully. 

The  marked  hypertrophy  and  shortening  of  the  thoracic 
elevators  are  evident  from  an  examination  of  the  cervical 
muscles  in  old-standing  cases  of  this  disease ;  not  only 
do  they  stand  out  prominently,  but  they  may  be  felt  to 
be  hard  and  tense  ;  and  when  we  reflect  that  the  sternum 
and  clavicles  are  permanently  raised,  considerably  in  some 
cases,  it  is  evident  that  there  must  be  very  considerable 
shortening,  for  how  otherwise  could  they  remain  tense? 
This  view  receives  further  confirmation  from  the  fact  that 
the  inspiratory  force  in  emphysema  predominates  over  the 
expiratory,  as  can  be  shown  by  the  manometer.  It  is 
found  that  the  inspiratory  force  remains  normal,  or  is 
even  increased,  while  the  expiratory  force  is  diminished.* 
This  we  may  explain  by  reference  to  the  hypertrophy  of  the 
inspiratory  muscles,  which  enables  them  to  maintain  a  high 
level  of  inspiratory  force  in  spite  of  the  fixity  of  the  chest, 
which,  however,  diminishes  expiratory  force.! 

*  '  Die  Pneumatische  Behandlung  der  Respirations  u.  Circulations 
Krankheiten,'  L.  Waldenburg,  1880,  p.  56. 

■f  The  important  part  which  loss  of  pulmonary  elasticity  and  over- 
action  of  the  inspiratory  muscles  play  in  the  production  of  the  large 
emphysematous  chest  suggested  itself  to  me  when  thinliing  over  the 
mechanism  of  the  expansion.  This  view  was,  however,  I  find,  advanced 
by  Dr.  liudd  nearly  sixty  years  ago,  when  he  expressed  himself  thus: 
'The  want  of  elasticity  in  the  lungs  is  the  real  cause  of  emphysema. 
The  powerful  muscles  of  mspiration  are  continually  tending  to  dilate 


RESPIRATORY   EXERCISES    IN    EMPHYSEMA       177 

The  degree  to  which  the  chest  expands  in  emphysema 
depends  upon  its  mobility  at  the  onset  of  the  disease,  and 
also  upon  the  vigour  and  activity  of  the  muscle-system. 
Thus  expansion  is  facilitated  by  free  mobility  of  the  chest. 
Little  enlargement  takes  place  in  senile  emphysema — i.e., 

the  chest,  and  hence  .  .  .  the  air-cells.  This  agency  is  not  counteracted 
as  it  should  be  by  the  natural  elasticity  of  the  lungs  ;  and  the  air-cells, 
as  well  as  the  cavity  of  the  chest,  are  permanently  dilated  '  (Med.  Cliir. 
Trans.,  xxiii.,  1840,  p.  '>T}. 

Cohnhcim  attributes  emphysema  in  a  large  number  of  cases  to  a 
congenital  defect  of  the  pulmonary  elastic  tissue  ('  Principles,  etc., 
of  Medicuae,'  3rd  edit.,  vol.  i.,  p.  967,  C.  H.  Fagge). 

Sir  Richard  Douglas-Powell  also  alludes  to  the  loss  of  pulmonary 
elasticity  as  a  factor  in  the  pathology  of  hypertrophous  emphysema, 
though  I  am  not  able  to  accept  all  his  deductions.  He  argues  thus : 
the  elasticity  of  the  lungs  is  greatly  diminished,  and  may  be  lost  in 
this  disease,  and  pulmonarj-  suction  thus  being  inadequate,  the  chest- 
walls  are  no  longer  sucked  in  and  bent  beyond  the  neutral  point  at  the 
end  of  an  ordinary  expiration ;  wherefore  the  thorax  will  have  the 
same  circumference  at  the  beginning  of  inspiration  as  normally  it  has 
at  the  end  thereof  [it  is  not  explained  why  the  chest  expands  consider- 
ably beyond  this  point  in  emphysema] ,  and  inspiration  is  no  longer 
aided  by  the  passive  recoil  of  the  ribs,  which  have  in  consequence 
to  be  lifted  with  every  inspiration  ('  Diseases  of  the  Lungs,'  4th  edit., 
chap.  X.).  This  explanation  does  not  appear  to  me  to  be  satisfactory, 
for  I  do  not  see  how  inspiratory  recoil  aids  inspiration,  since  it  is 
neutralized  by  pulmonary  suction,  upon  which,  indeed,  it  depends. 
Suppose  the  latter  to  be  represented  by  six,  the  inspiratory  recoil  of 
the  ribs  operating  in  the  opposite  direction  will  be  represented  by  the 
same  numeral,  and  the  resultant,  as  far  as  inspiratory  movement  is 
concerned,  is  nil.  Disappearance  of  pulmonary  suction  impUes  the 
disappearance  of  inspiratory  recoil,  but  such  disappearance  will  make 
no  difference  in  the  amount  of  inspiratory  force  needful.  The  need 
for  increased  inspiratory  force,  referred  to  by  Douglas-Powell,  is,  I 
believe,  due  to  that  expansion  of  the  chest  which  is  a  feature  of  the 
disease ;  for  the  more  the  chest  is  enlarged,  the  more  difficult  does  it 
become  to  enlarge  it  further. 

Jenner  develops  Budd's  idea,  and  refers  to  the  (possible)  influence  of 
duuinished  costal  elasticity  in  the  pathology  of  hypertrophous  emphy- 
sema, contending  that  this  interferes  with  proper  costal  recoil  during 
expiration,  which  therefore  is  imperfectly  performed. 

VI 


178  RESPIRATORY   EXERCISES 

the  so-called  '  atrophous  '  variety — because  it  does  not  come 
on  until  the  chest  has  acquired  the  iSixity  peculiar  to  old 
age  ;  but  when  the  disorder  begins  in  early  or  middle  life, 
■while  the  thorax  is  still  mobile,  considerable  thoracic 
expansion  may  occur.  Similarly,  expansion  tends  to  be 
more  pronounced  the  more  muscular  the  individual.  It  is 
therefore  apt  to  be  small  in  those  with  feeble  muscles. 
Hence  an  additional  reason  why  the  chest  should  not 
expand  in  senile  emphysema.  On  the  other  hand,  those  of 
powerful  muscular  build  are  apt  to  get  very  large  chests  if 
they  develop  emphysema,  and  it  is  not  therefore  surprising 
that  the  most  pronounced  cases  of  large-lunged  emphysema 
are  generally  met  with  in  those  following  laborious  occupa- 
tions. 

The  expansion  of  the  chest  is  usually  most  marked  in  its 
upper  part.  This  may  be  explained  by  the  effect  during 
cough  of  the  sudden  contraction  of  the  abdominal  muscles 
and  uplifting  of  the  diaphragm  in  driving  the  air  from 
the  lower  regions  of  the  lungs  into  their  apical  portions, 
which  thus  tend  to  thrust  the  upper  part  of  the  chest 
outwards.  The  powerful  contraction  of  the  abdominal 
muscles  that  then  takes  place  leads  to  an  actual  contraction 

Wilson  Fox,  who  gives  the  most  masterly  account  of  emphysema 
that  I  have  met  with,  supports  Budd  and  Jenner,  aiid  supplies,  as 
I  think,  a  most  important  link  in  the  chain  of  argument,  viz.,  the 
tendency  of  dyspnoea  to  excite  the  inspiratory  muscles  more  than  the 
expiratory.  He  observes  that  the  emphysematous  chest,  '  especially 
vmder  exertion,  is  expanded  to  its  fullest  limits  by  the  muscles  of  in- 
spiration, while  the  subsequent  retraction  necessary  for  the  proper 
performance  of  respiration  is  hindered  by  the  want  of  elasticity  in 
these  structures.  As  a  consequence,  a  potential  dyspnoea  is  produced, 
the  immediate  reflex  effect  of  which  is  to  create  a  tendency  to  further 
deep  inspirations,  and  the  inspiratory  muscles  become  as  a  consequence 
hypertrophied.'     (Op.  cit.,  p.  158.) 

Neither  Budd,  Jenner,  nor  Wilson  Fox,  however,  explain  satisfac- 
torily why  the  chest  is  kept  jyermanently  expanded  and  fixed. 


RESPIRATORY   EXERCISES   IN    EMPHYSEMA       179 

of  the  lower  chest,  which  therefore  cannot  be  distended 
during  the  cough  ;  but  the  upper  chest,  not  being  so  imme- 
diately under  the  control  of  the  expiratory  muscles,  may 
sufier  temporary  expansion,  and  this  frequent  repetition  may 
render  permanent.  It  is  on  these  lines  that  Jenner  and 
Mendelssohn  explain  the  frequent  occurrence  of  emphysema 
at  the  apices. 

I  have  laid  stress  upon  the  mechanism  of  thoracic  expan- 
sion in  hypertrophic  emphysema  because  the  process  is 
largely  an  injurious  one,  and  should,  as  such,  be  combated. 
It  is  harmful  because  it  leads  to  excessive  stretching  of  lung 
tissue,  and  this,  as  Budd  insists,  is  alone  sufficient  to  induce 
emphysema.  Let  us  suppose  healthy  lungs  to  lose  their 
elasticity,  and  the  chest  to  assume  m  consequence  the  posi- 
tion of  super-extraordinary  inspiration.  The  continuous 
stretching  of  the  alveoli  thus  induced  will  not  only  diminish 
pulmonary  elasticity  still  further,  but  will  so  interfere  with 
alveolar  nutrition  (which  is  dependent  upon  the  ample 
rhythmic  relaxation  of  the  alveoli)  as  to  give  rise  to  so- 
called  compensatory  emphysema.  It  would  appear  there- 
fore that  mere  loss  of  pulmonary  elasticity  is,  by  inducing 
thoracic  expansion,  sufficient  of  itself  to  bring  about  em- 
physema. 

The  loss  of  pulmonary  elasticity  in  emphysema  has  a 
further  injurious  effect  in  that  by  diminishing  pulmonary 
suction  it  interferes  with  an  important  accessory  force  of 
the  circulation. 

The  progressive  enlargement  of  the  chest  in  emphysema 
tends  to  produce  another  evil — its  fixation,  and  thus  to 
diminish  the  expiratory  range.  In  extreme  cases  the  bony 
thorax  may  indeed  be  bereft  of  respiratory  power,  being 
either  immobile,  or  admitting  only  movement  as  a  whole 
without  any  alteration  of  capacity.  Eespiration  is  then 
practically  confined  to  the  diaphragm,  which,  however,  does 

12—2 


180  RESPIRATORY   EXERCISES 

not  move  with  its  normal  freedom  on  account  of  its  flat- 
ness, due  to  the  expansion  of  the  lower  chest  and  the 
diminished  suction  on  its  upper  surface.  It  has,  in  fact, 
been  said  that  in  some  extreme  cases  it  is  altogether  incapable 
of  enlarging  the  thorax,  its  contraction  causing,  on  the  con- 
trary, an  actual  drawing-in  of  the  ribs.*  I  have  not,  how- 
ever, met  with  a  case  of  emphysema  in  which  the  diaphragm 
had  entirely  lost  its  inspiratory  power,  and  it  is  certain  that 
in  most  cases  a  fair  quantity  of  air  can  be  inspired  by  its 
means,  expiration  being  chiefly  effected  by  a  forcible  con- 
traction of  the  expiratory  muscles,  whereby  the  diaphragm 
is  thrust  upwards.  If  in  cases  of  this  kind  the  hand  be 
placed  upon  the  belly,  it  will  be  felt  to  obtrude  during 
diaphragmatic  descent,  and  to  become  hard  during  expira- 
tion from  contraction  of  the  abdominal  muscles. 

The  immobility  of  the  thorax  is  one  of  the  worst  aspects 
of  emphysema,  and  has  not  received  the  attention  it 
deserves.  The  diminution  in  respiratory  area  is  serious 
enough,  but  this  would  be  largely  compensated  for  if  only 
the  patient  could  expire  adequately.  The  breathlessness  is 
due  far  more  to  the  meagreness  of  the  tidal  current  than  to 
the  limitation  of  the  respiratory  surface,  and  be  it  noted,  as 
Walshe  long  ago  pointed  out,  the  emphysematous  patient 
does  not  make  up  for  deficient  depth  in  breathing  by 
increased  rate. 

That  the  diminished  expiratory  range  in  emphysema  is 
due  to  the  fixity  of  the  thorax  I  have  no  doubt.  I  can  find 
no  other  adequate  cause.     It  is  frequently  attributed  to  loss 

*  Thus  Wilson  Fox  writes  :  '  The  contraction  of  the  diaphragm  may 
in  some  cases  even  appear  to  retract  the  lower  ribs,  acting  as  it  some- 
times does  from  a  lower  level,  which  in  expiration  may  even  be  below 
that  of  the  ribs  The  epigastrium  may  thus  sink  during  inspiration 
and  bulge  during  expiration,  owing  to  the  slowness  with  which  the  air 
escapes,  wliile  the  chest  is  compressed  by  the  accessory  muscles  of 
expiration.'     Oj).  cit.,  p.  171. 


RESPIRATORY    EXERCISES    IN    EMPHYSEMA       181 

of  pulmonary  elasticity*  ;  but  though  such  loss  prevents 
ordinary  expiration  from  taking  place  by  simple  elastic 
recoil,  as  happens  under  normal  conditions,  it  cannot 
account  for  the  inability  of  the  patient  to  expire  freely  by 
means  of  the  most  powerful  expiratory  effort.  Nor  can  the 
limited  expiratory  range  be  attributed  to  impediment  in  the 
air-passages.  It  has  been  argued,  for  instance,  that  the 
loss  of  pulmonary  elasticity  in  emphysema  *  interferes  with 
that  condition  of  permanent  patency  in  which  the  small 
bronchi  are  normally  held  by  the  constant  traction  upon 
them  of  the  elastic  lung  from  all  sides.  In  emphysema 
this  traction  becomes,  in  expiration  at  first,  entirely  neutra- 
Hzed,  and  in  marked  cases  collapse  of  the  bronchioles  must 
occur  during  expiration. 'f  It  seems,  however,  doubtful 
whether  this  loss  of  pulmonary  elasticity  leads  in  any 
marked  degree  to  such  collapse,  seeing  that  in  this  disease 
the  alveolar  walls  are  considerably  stretched.  Be  this  as  it 
may,  it  is  certain  that  any  obstruction  thus  arising  is  in- 
sufficient to  account  for  the  limited  expiratory  range,  seeing 
that  air  can  be  expressed  from  the  lungs  by  the  thrusting 
upward  of  the  diaphragm  as  the  result  of  the  contraction  of 
the  abdominal  muscles.  In  extreme  cases  the  breathing 
may  be  almost  wholly  abdominal,  and  this  indicates  that 
fixation  of  the  chondro-osseous  thorax  is  the  cause  of  the 
diminished  range. 

Treatment  of  Emphysema.— From  the  foregoing  observa- 
tions it  is  manifest  that  in  the  treatment  of  emphysema  we 
should  seek  (a)  To  preserve  the  elasticity  of  the  lungs  and 
cartilages;  (b)  by  preventing  overaction  of  the  costal 
elevators  to  check  thoracic  expansion  ;  (c)  to  maintain  the 
normal  mobility  of  the  thorax. 

(a)  I  have  already  dealt  with  the  means  of  preserving 

*  See  Wilson  Fox,  o^.  cit.,  p.  171. 

t  Sir  Richard  Douglas-Powell,  o^).  cit.,  pp.  194,  195. 


182  RESPIRATORY   EXERCISES 

pulmonary  elasticity  (see  p.  7).  I  would  here  only  insist 
upon  the  importance  of  avoiding  strong  muscle-efforts*  and 
all  exercises  calculated  to  induce  great  dyspnoea.! 

(h)  In  order  to  prevent  overaction  of  the  inspiratory 
muscles,  and  thus  to  check  thoracic  expansion,  the  patient 
must  guard  against  all  causes  likely  to  induce  dyspnoea, 
which,  as  we  have  seen,  excites  the  inspiratory  muscles 
more  than  the  expiratory.  We  should  further  seek  to 
antagonize  the  former  by  calling  the  latter  into  play.  From 
the  earliest  phase  of  the  disease  recourse  should  be  had  to 
systematic  expiratory  exercises.  Thoracic  expansion  begins 
long  before  the  recognised  signs  of  emphysema  show  them- 
•selves,  and  it  is  in  this  early  phase  of  the  disease  that  the 
expiratory  exercises  should  be  begun.  Unhappily  the 
patient  does  not  often  come  under  the  physician's  notice 
for  emphysema  until  the  disease  has  made  considerable 
progress,  but  it  may  frequently  be  observed  when  he  is  con- 
sulted for  some  other  condition. 

The  expiratory  exercises  I  adopt  are  very  simple.  They 
consist  in  the  deepest  possible  expirations.     Starting  from 

*  I  have  now  under  observation  a  man,  aet.  20,  whose  chest  is  very 
emphysematous  and  fixed.  There  is  no  history  of  bronchitis,  but 
inquiry  eUcits  the  fact  that  for  the  past  six  years,  i.e.,  since  the  age  of 
fourteen  years,  he  has  been  engaged  in  an  occupation  which  requires 
him  constantly  to  hft  heavy  weights.  It  is  no  unusual  thing  for  him 
to  have  to  lift  two  hundredweight !  In  this  case  there  can  be  Httle 
doubt  that  the  emphysema  is  due  to  loss  of  pulmonary  elasticity 
resulting  from  heightened  intra-alveolar  tension,  coupled  with  exces- 
sive inspiratory  action  consequent  upon  dyspnoea. 

•f  ArValdenburg  cites  the  case  of  a  student  who  became  emphyse- 
matous in  consequence  of  rapidly  mounting  several  flights  of  stairs 
daily.  Waldenburg  attributed,  and  I  think  correctly,  the  loss  of  pul- 
monary elasticity  and  resulting  emphysema  in  this  case  to  the  long- 
continued  over-expansion  of  the  lung  resulting  from  great  dyspnoea. 
He  also  refers  to  an  interesting  case  of  emphysema  similarly  induced 
in  a  professional  lady  swimmer  who  used  to  remain  three  minutes 
under  the  water.     (Waldenburg,  ojj.  cit,  pp.  .'50-52.) 


RESPIRATORY    EXERCISES    IX    EMPHYSEMA       183 

the  position  of  ordinary  inspiration  the  patient  should 
expire  to  the  utmost  with  mouth  wide  open,  the  body  being 
bent  forward  the  while,  so  as  to  favour  compression  of  the 
diaphragm  from  below.  These  exercises  should  be  practised 
for  at  least  half  an  hour  twice  daily.  Special  exercises  of 
the  abdominal  muscles  should  also  be  resorted  to.  Thus 
the  patient,  lying  supine,  is  directed  to  raise  his  body,  the 
legs  being  held  by  an  assistant  if  necessary.  In  this  way 
the  great  depressors  of  the  thorax  may  be  considerably 
developed.  Eetraction  of  the  belly,  by  which  the  transver- 
salis  is  exercised,  should  be  frequently  practised,  and  thus 
the  tendency  to  undue  opening- out  of  the  costal  arch  pre- 
vented. Massage  and  faradisation  of  the  abdominal 
muscles  may  in  some  cases  be  called  for. 

Apart  altogether  from  the  advantage  gained  in  thus 
antagonizing  the  costal  inspiratory  muscles,  it  is  of  the 
greatest  advantage  to  the  emphysematous  patient  to  have 
firm  and  well  -  developed  abdominal  muscles,  since  a  lax 
state  of  these  predisposes  to  many  evils  which  tell  against 
him,  such  as  flatulence,  costiveness,  dislocation  of  the 
abdominal  viscera,  and  the  accumulation  of  blood  in  the 
portal  area. 

(c)  By  means  of  the  expiratory  exercises  just  described 
we  may  also  check  the  tendency  to  fixation  of  the  thorax, 
indeed,  we  can  in  this  way  generally  increase  thoracic 
mobility  considerably.  Defective  thoracic  mobility  in  an 
apparently  healthy  man  is  always  suggestive  of  com- 
mencing emphysema.  Here  the  use  of  the  spirometer 
comes  in.  If  we  find  a  man  of  forty  with  no  apparent 
lung  disease  to  have  a  chest  measurement  of  38  inches, 
and  a  vital  capacity  of  only  230  cubic  inches,  we  may  be 
pretty  sure  that  he  is  on  the  road  to  emphysema.  I  would 
utter  a  word  of  caution  against  the  assumption  that 
thoracic  girth  is  a  safe  measure  of  pulmonary  efficiency. 


184  RESPIRATORY    EXERCISES 

Vital  capacitj^  is  a  much  more  accurate  test.  The  spi- 
rometer often  shows  a  chest  of  34  inches  to  have  a  greater 
vital  capacity  than  one  of  38  inches. 

When  the  chest  is  very  fixed  it  may  be  necessary  to 
resort  to  special  means  to  promote  the  expiratory  move- 
ment. In  addition  to  those  already  described  (p.  157),  we 
maj^  cause  the  patient  to  expire  forcibly  into  a  chamber  of 
rarefied  air,  so  as  to  reduce  the  '  residual '  air  to  a  minimum* 
or  he  may  sit  in  a  chamber  of  compressed  air,  and  expire 
into  the  external  atmosphere. 

The  inhalation  of  condensed  air  would  theoretically 
appear  to  be  wrong,  seeing  that  it  promotes  thoracic 
expansion.  As  a  matter  of  fact,  it  may  prove  of  great 
service  when  dyspnoea  is  great,  by  favouring  the  oxygena- 
tion of  blood.  The  patient  may  sit  either  in  the  com- 
pressed air  chamber,  or  inspire  compressed  air,  in  either  case 
expiring  into  rarefied  air.  It  need  scarcely  be  said  that  the 
inhalation  of  rarefied  air  is  hurtful,  and  hence  emphyse- 
matous patients  should  not  reside  in  mountainous  districts. 

The  chief  drawback  to  the  treatment  just  sketched  out  is 
getting  the  patient  to  persevere  in  it  long  enough.  It  involves 
a  considerable  sacrifice  of  time,  and  is  apt  to  grow  irksome. 
Few  good  results  in  this  world,  however,  can  be  obtained 
without  both  pains  and  patience,  and  certainly  the  end 
gained  in  this  instance  is  worthy  the  cost. 


CHAPTER  XXIII. 

RESPIRATORY  EXERCISES  IN  HEART  DISEASE. 

Kespiratoky  exercises  are  valuable  adjuncts  in  the  treatment 
of  heart  disease,  for  they  favour  the  development  of  the  lungs, 
and  thereby  diminish  their  tendency  to  disease— a  tendency 
it  is  most  important  to  check,  owing  to  the  extra  work  lung 
disease  casts  upon  the  right  heart.  The  importance  of 
securing  the  fullest  possible  development  of  the  lungs  in 
heart  disease  has  been  strangely  overlooked.  The  more 
completely  the  lungs  are  developed,  the  more  capacious  is 
the  pulmonary  vascular  system,  and  the  less  is  the  resist- 
ance which  it  opposes  to  the  right  heart,  pulmonary 
resistance  being  in  inverse  ratio  to  pulmonary  capacity. 
This  fact  is,  indeed,  instinctively  taken  advantage  of  in 
heart  disease,  in  which  we  may  frequently  observe  over- 
action  of  the  inspiratory  muscles  and  an  increase  in  the 
mean  size  of  the  chest.  Not  only  is  the  breathing  area  in 
this  way  increased,  but  the  pulmonary  vascular  capacity 
also  ;  and  hence  the  work  of  the  right  heart  is  diminished. 
Now,  all  organic  cardiac  disease,  but  especially  mitral 
affections  and  primary  disease  of  the  right  heart,  tend  to 
cast  extra  work  upon  the  right  side  ;  and  it  is,  therefore,  of 
the  utmost  importance  in  all  cases  of  heart  disease  to  secure 
the  maximum  development  of  the  lungs.  Consider,  for 
instance,  what  happens  in  mitral  disease.  In  both  ob- 
struction and  leakage  at  the  mitral  orifice  the  pressure  in 


186  RESPIRATORY    EXERCISES 

the  pulmonary  circuit  is  increased,  a  fact  which  proves  that 
the  resistance  which  the  right  heart  has  to  overcome  is 
augmented.  This  increased  pressure  obtains  throughout 
the  entire  pulmonary  segment,  both  in  the  pulmonary 
artery  itself  and  in  the  pulmonary  veins  as  they  open  into 
the  left  auricle.  The  augmented  pressure  in  the  latter  is 
obviously  compensatory,  tending,  as  it  does,  to  minimize 
the  evil  effect  of  the  valvular  disease.  Now,  the  larger  the 
lungs,  so  much  the  less  will  be  the  extra  force  demanded  of 
the  right  heart  in  order  to  bring  about  the  necessary  in- 
crease of  pressure  in  the  pulmonary  veins,  and  the  longer 
will  the  right  heart  be  able  to  hold  out.  Given  two  indi- 
viduals suffering  from  mitral  disease,  and  identical  in  all 
respects  save  that  the  one  has  well-developed  and  the  other 
ill-developed  lungs,  the  prognosis  will  be  very  much  better 
in  the  former  case  than  in  the  latter. 

It  follows  that  in  all  cases  of  failing  heart  every  care 
should  be  taken  to  keep  the  lungs  in  as  perfect  a  state  of 
efficiency  as  possible.  I  have  seen  many  deaths  from  heart 
disease  which  could  have  been  averted  had  this  cardinal 
fact  been  acted  upon.  It  is  a  point  which  we  should  always 
impress  upon  the  patient.  As  a  rule  it  is  upon  the  lungs 
rather  than  upon  the  heart  that  his  attention  should  be 
concentrated. 

Not  only  do  respiratory  exercises  do  good  in  heart  disease 
by  promoting  pulmonary  efficiency,  but  also  by  aiding  the 
circulation  of  the  l^lood  ;  for,  as  we  have  seen,  it  is  possible 
so  to  modify  the  respirations  as  materially  to  facilitate  the 
transference  of  blood  from  the  veins  to  the  arteries.  By 
their  means  the  lymphatic  circulation  may  also  be  aided, 
lymph  being  pumped  from  the  peritoneal  cavity  into  the 
pleura;,  from  the  latter  and  from  the  pericardium  into  their 
respective  lymphatics,  and  from  the  two  thoracic  ducts  into 
the  great  veins.     Such  aids  to  the  lymph  flow  are  very 


RESPIRATORY    EXERCISKS    IN    HEART    DISEASE     187 

helpful  in  heart  disease,  especially  when  there  is  a  tendency 
to  oedema  and  ascites.  Forced  abdominal  breathing  should 
be  employed  for  removing  the  latter. 

I  would  emphasize  the  fact  that  it  is  not  merely  in  mitral 
disease  that  breathing  exercises  are  useful ;  they  should  be 
resorted  to  both  in  aortic  valve  disease  and  in  weakness  of 
the  heart-muscle,  seeing  that  the  evil  effects  in  both  cases 
tend  to  w'ork  backwards  beyond  the  mitral  ring,  and  no 
sooner  does  this  occur  than  the  right  heart  feels  the  strain. 

It  is  largely  through  their  influence  on  the  respiratory 
movements  that  such  exercises  as  walking  (especially  hill- 
climbing),  running,  swimming,  rowing,  riding,  not  to  mention 
talking  and  singing,  are  useful  in  heart  disease.  Even  the 
so-called  Nauheim  treatment  benefits  in  large  measure  by 
causing  an  increase  in  the  mean  size  of  the  chest,  and  thus 
favouring  the  pulmonary  circulation.* 

How  profoundly  the  breathing  is  affected  in  hill-climbing 
is  well  shown  in  the  following  passage  from  Oertel  : 

'  If  the  locomotion  be  extended  till  the  patient  ascends  elevations  or 
mountains,  not  only  is  there  a  great  increase  of  sweating,  but  the 
patient  soon  breathes  only  by  summoning  all  the  means  at  his  com- 
mand. He  is  obliged  to  stop  every  ten  or  tw^elve  steps.  The  frequent 
and  loudly  audible  respirations  begui  with  long-drawn  and  deep  in- 
spirations, with  spasmodic  contraction  of  the  diaphragm,  and  the 
patient  supports  himself  against  some  fixed  object,  his  alpenstock,  e.fj., 
the  pectoral  muscles  labouring  hard,  and  the  ribs  being  raised  by  tlie 
intercostals.  The  expiration,  on  the  other  hand,  is  but  short,  and  is 
quickly  followed  by  the  long-drawn  inspu-ation.  The  same  thing 
occurs  every  fifteen  or  twenty  steps,  without  any  diminution  in  the 
intensity  of  the  respu'atory  movements,  and  the  exertion  can  go  on  for 
hours  with  but  slight  interruption.  But  by  exercise  the  respiratory 
muscles,  lilie  any  other  muscles,  undergo  a  gi-eat  increase  of  their 
functional  capacity.'  f 

*  For  the  author's  views  on  the  rationale  of  the  Nauheim  treatment, 
see  Brit.  Med.  Jour.,  vol.  ii.,  p.  712,  1896,  and  Lancet,  1896,  vol.  I., 
p.  951. 

t  Von  Ziemssen's  '  Handbook  of  General  Therapeutics,'  vol.  vii.,  p.  32. 


188  RESPIRATORY   EXERCISES 

Oertel  here  refers  to  the  great  shortness  of  expiration  as 
compared  with  inspiration.  He  might  have  added  that  the 
expirations  are  not  only  short  but  incomplete,  and  that  the 
mean  size  of  the  chest  is  therefore  increased.  I  have 
already  pomted  out  that  this  is  the  mode  of  breathing  best 
calculated  to  facilitate  the  pulmonary  flow,  and  thus  to 
relieve  an  overburdened  right  heart. 

The  following  passage  shows  that  Oertel  himself  re- 
cognised that  some  good  end  was  served  by  this  altered 
mode  of  breathing : 

'  Through  the  powerful  and  involuntary  respiration  caused  by  hill- 
climbing  the  thorax  enlarges  in  all  its  dunensions,  the  lungs  attain 
then*  utmost  possible  resjnratorjj  disteiision,  and  from  the  enlargement 
of  their  vessels  are  able  to  receive  far  greater  quantities  of  blood. 
The  intensity  of  the  respiratory  movements,  which  are  conducted  with 
all  the  strength  possible,  causes  the  aspiration  of  more  blood  into  the 
thorax  .  .  .  the  exit  of  the  blood  from  the  right  heart  is  thus  facili- 
tated. .  .  . 

'  By  these  processes  m  the  lungs,  part  of  the  hindrances  exciting  and 
keeping  up  the  circulatory  derangement  are  removed,  and  the  cu'cula- 
tion  becomes  freer.  Inasmuch  as  for  a  long  time  after  each  ascent  the 
thorax  has  a  greater  mobility  and  expands  more  easilj^,  so  the  alteration 
in  the  pulmonar}^  circulation  also  outlasts  the  period  of  the  ascent ; 
and  by  repetition  of  these  muscular  exertions  we  are  enabled  to  bring 
about  a  permanent  increase  in  the  capacity  of  the  pulmonary  vessels 
by  increase  of  thoracic  mobility,  enlargement  of  the  thoracic  space, 
and  increase  of  pulmonary  capacity.'* 

I  will  not  say  anything  further  on  the  treatment  of  heart 
disease  in  this  place,  as  I  propose  to  deal  with  the  subject 
at  length  in  a  separate  work. 

*  Von  Ziemssen's  '  Handbook  of  General  Therapeutics,'  vol.  \u.., 
pp.  165,  166. 


CHAPTER  XXIV. 

RESPIRATORY  EXERCISES  IN  THE  TREATMENT  OF 
NERVOUS  DISEASES. 

Great  benefit  can  be  derived  from  respiratory  exercises  in 
functional  diseases  of  the  nervous  system.  This  is  not 
surprising  when  we  reflect  upon  their  influence  on  the 
circulation  of  blood  and  lymph.  That  they  exert  a  pro- 
found influence  upon  the  brain  is  shown  by  the  increased 
power  of  sustained  voluntary  effort  which  they  confer 
(see  p.  141),  as  also  by  the  giddiness  which  they  not  in- 
frequently induce,  especially  when  first  undertaken.  By 
accelerating  the  flow  of  blood  and  lymph  in  the  nervous 
system,  they  not  only  increase  the  supply  of  oxygen  and 
food-stuffs,  but  they  also  promote  the  withdrawal  of  waste- 
products,  and  all  this,  be  it  noted,  while  the  nervous  system 
remains  in  a  state  of  comparative  rest.  Nor  must  we  in 
this  connection  neglect  the  beneficial  influence  of  respiratory 
exercises  on  the  digestive  viscera,  notably  on  the  liver. 
There  can  be  little  doubt  that  auto -intoxication  plays  a 
prominent  part  in  the  causation  of  functional  nervous 
disorders,  and  that  such  auto-intoxication  largely  results 
from  faulty  action  of  these  viscera ;  and  I  cannot  but  think 
that  much  of  the  benefit  derived  from  respiratory  exercises 
in  nervous  disease  is  wrought  through  the  digestive  system. 
Finally,  the  influence  of  suggestion,  which  plays  so  pro- 
minent a  part  in  therapeutics,  must  not  be  forgotten. 


190  RESPIRATORY   EXERCISES 

But  whatever  be  the  mode  in  which  respiratory  exercises 
benefit,  in  functional  nervous  disorder  their  good  effect  is 
unmistakable.  One  rarely  fails  to  get  benefit  from  them  in 
neurasthenia ;  and  in  inordinate  blushing  this  mode  of 
treatment  has  yielded  surprising  results.  Those  who  have 
had  no  experience  of  this  disease — for  such,  in  truth,  it  is — 
can  have  no  conception  of  the  misery  it  may  cause.  I  have 
known  it  to  prompt  to  suicide.  In  all  such  extreme  cases 
the  sufferer  is  morbidly  self-conscious,  and  is  of  nervous 
temperament,  although  I  have  frequently  been  told  by 
patients  "of  this  kind  that  if  only  the  tendency  to  blush 
were  removed  all  would  be  well  with  them,  this  being,  as 
they  thought,  the  beginning  and  end  of  their  sufferings.  I 
have,  however,  met  with  a  number  of  cases  in  which 
morbid  self -consciousness  and  other  evidences  of  the 
nervous  diathesis  have  persisted  after  the  morbid  tendency 
to  blush  has  been  cured. 

The  following  is  an  instance  of  morbid  blushing  cured  by 
respiratory  exercises : 

M.,  set.  28.  Until  set.  14  lie  was  devoid  of  morbid  self-consciousness. 
At  this  time  he  one  day  suddenly  and  unexpectedly  blushed  in  class. 
This  was  made  the  subject  of  chaff  by  his  schoolfellows ;  thence- 
forward he  became  recognised  as  a  blusher,  and  he  was  so  plagued 
and  tormented  that  school  became  unbearable,  and  he  begged  his 
parents  to  take  him  away,  which  they  did.  Hereafter  his  entire  life 
was  dominated  by  the  dread  of  blushing,  and  of  being  the  object  of 
remarks  by  others.  He  spent  two  years  with  a  family  in  Germany,  in 
order  to  avoid  association  with  other  boys,  and  after  being  under  a 
tutor  in  England  entered  the  University.  Here  .he  was  so  fearful  of 
being  chaft'ed  by  the  men  that  he  kept  entirely  to  himself,  making  no 
friends,  and  eventually  finding  himself  compelled  to  leave  college 
without  graduating.  After  this  his  time  was  mainly  spent  in  travel,  so 
as  to  avoid  close  association  with  others,  and  in  the  vain  endeavour  to 
flee  from  his  trouble.  The  fear  that  he  might  at  any  moment  blush 
and  be  an  object  of  derision  was  never  absent  all  these  j-ears.  It 
formed  the  background  to  all  his  thoughts.  He  went  to  sleep  with  it, 
it  troubled  his  dreams,  he  awaked  with  it.     He  felt  himself  debarred 


THE    TREATMENT    OF    NERVOUS    DISEASES        191 

from  marriage,  and,  indeed,  from  all  social  intercourse ;  and,  in  spite 
of  youth,  position,  and  sound  physical  health,  his  life  was  so  utterly 
miserable  that  he  had  serious  thoughts  of  suicide.  It  was  then  that  I 
first  saw  him. 

It  would  need  more  space  than  I  can  afford  to  describe 
the  method  of  treatment  which  was  adopted  with  entire 
success  in  this  case.  It  was,  of  course,  in  large  degree 
psychical,  but  the  result  was  achieved  mainly,  I  believe,  by 
respiratory  exercises.  The  patient  threw  himself  enthusi- 
astically into  the  treatment,  and  for  many  months  spent  an 
hour  every  morning  and  evening  in  exercises.  This  gradu- 
ally lessened  the  vaso-motor  instability.  The  dread  that 
the  tendency  to  blush  would  return  persisted  for  some  time, 
but  eventually  yielded  to  mental  treatment. 

The  subjoined  is  a  case  of  severe  hypochondria  in  which 
respiratory  exercises  did  great  good  : 

M.,  set.  30.  Has  for  some  3'ears  thrown  great  energy  into  his  busi- 
ness. Lives  in  constant  fear  of  having  some  deadly  malady.  If  he 
feels  a  pain,  or  unpleasant  sensation  anywhere,  at  once  fancies  it  is  the 
precursor  of  some  terrible  illness,  and  even  after  he  has  been  assured, 
and  apparently  convinced  of  the  contrary,  will  again  and  again  recur 
to  the  matter.  Thus  on  one  occasion  he  experienced  numbness  in  the 
feet,  and  it  was  with  the  greatest  difficulty  he  could  be  persuaded  that 
it  was  not  locomotor  ataxy ;  and,  on  another  occasion,  an  urticarial 
rash  made  him  fancy  he  was  going  to  get  typhoid. 

This  patient  rapidly  improved  under  a  course  of  respira- 
tory exercises,  and  though  he  is  still  inclined  to  exaggerate 
the  importance  of  trivial  symptoms,  he  is  practically 
cured. 

Note. — As  showing  how  profoundly  breathmg  exercises  affect  the 
nervous  system,  I  may  mention  that  a  patient  now  under  treatment 
informs  me  that  his  susceptibility  to  alcohol  is  very  decidedly  diminished 
by  taking  a  series  of  deep  breaths. 


CHAPTEE  XXV. 

RESPIRATORY  EXERCISES  IN  THE  TREATMENT  OF 
DIGESTIVE  DISORDERS. 

DisoEDERS  of  digestion  may  often  be  greatly  benefited  by 
breathing  exercises,  which  are  capable  of  profoundly  influ- 
encing the  circulation  of  lymph  and  blood  m  the  digestive 
viscera.  It  must  be  remembered  that  general  muscle- 
exercises,  such  as  walking,  runnmg,  cycling,  are  incapable 
of  producing  such  a  localized  effect,  for  in  their  case  the 
effect  upon  the  circulation  is  widespread,  the  splanchnic 
circulation  being  often  depressed,  rather  than  stimulated, 
owing  to  the  determination  of  a  large  mass  of  blood  to  the 
musculo-cutaneous  system.  Hence  it  is  that  active  muscle- 
exercise  after  a  meal  tends  to  retard,  rather  than  to  pro- 
mote, digestion.  But  by  suitable  and  specially-adapted 
breathing  exercises  we  are  able  to  determine  a  large  flow  of 
blood  to  the  splanchnic  area,  and  at  the  same  time  to 
quicken  the  flow  through  it,  and  we  are  also  able  to 
accelerate  the  flow  of  chyle.  As  a  result,  the  nutrition  of 
the  liver  and  alimentary  tube  is  stimulated.  The  latter 
acquires  increased  tone,  and  is  thus  enabled  to  contract 
more  effectively  upon  its  contents,  while  the  secretion  of  the 
digestive  juices  and  the  absorption  of  the  food-stuffs  are 
promoted. 

Most  forms  of  dyspepsia,  gastric  and  intestinal,  benefit  by 
suitable  breathing  exercises,  but  perhaps  the  atonic  forms 
chiefly.    Intestinal  dyspepsia  has  not  yet  received  the  atten- 


THE   TREATMENT   OF   DIGESTIVE    DISORDERS      193 

tion  it  merits.  Many  a  one  who  does  not  suffer  from  any  of 
the  obtrusive  symptoms  of  gastric  dyspepsia,  such  as  pain, 
flatulence,  weight,  and  acidity,  and  who  would  stoutly  deny 
the  charge  of  being  dyspeptic,  is  a  martyr  to  intestinal 
dyspepsia  and  to  the  many  forms  of  blood-poisoning  which 
it  entails.  In  cases  of  this  kind  we  shall  often  find  breath- 
ing exercises  a  most  valuable  adjunct  to  other  treatment. 

'  As  regards  the  movements  of  the  stomach  proper,' 
writes  Allchin,*  'there  is  reason  to  believe  that  they  are 
capable  of  being  aided  in  their  effect  upon  the  gastric  con- 
tents by  the  movements  of  the  diaphragm  and  even  of  the 
heart,  which  may  together  be  sufficiently  effective  to  com- 
pensate for  the  complete  absence  of  the  stomach  peristalsis 
when  that  organ,  by  adhesions  or  other  causes,  is  incapable 
of  acting.'  If  such  is  the  case,  how  much  more  likely  are 
we  to  act  mechanically  upon  the  stomach  (and  intestines) 
by  special  exercises  of  the  diaphragm  and  anterior  abdominal 
muscles !  How  potently  these  act  is  well  shown  by  their 
power  to  dislodge  flatus.  This  in  itself  is  no  small  gain, 
seeing  how  distressing  are  the  symptoms  resulting  from  its 
mere  mechanical  presence. 

■  These  exercises  will  be  found  of  great  benefit  in  treating 
constipation.  Quite  recently  a  patient  to  whom  I  had  recom- 
mended them  for  quite  another  cause  wrote,  saying  that  he 
intended  to  persevere  in  them  if  only  because  they  enabled 
him  to  have  a  daily  evacuation. 

In  selecting  the  exercises  for  dyspepsia,  we  should  choose 
those  which  have  the  most  effect  upon  the  abdominal 
circulation.  One  of  the  most  valuable  is  alternate  con- 
traction of  the  diaphragm  (while  firm  pressure  is  made  on 
the  al)domen)  and  retraction  of  the  belly.  The  exercises 
for  strengthening  the  abdominal  muscles  (especially  when 
the  latter  are  flabby)  will  also  be  found  of  the  greatest  service. 

*  Lancet,  1897,  vol.  ii.,  p.  1031. 

IS 


CHAPTEE  XXVI. 

RESPIRATORY  EXERCISES  IN  OTHER  DISEASES. 

Eespiratory  exercises  may  be  employed  with  benefit  in 
many  other  diseases  than  those  ah'eady  mentioned.  To 
refer  to  some  of  these  briefly. 

Gall-stones. — William  Hunter  has  shown  that  catarrh  of 
the  gall-bladder  and  bile-ducts  plays  an  important  part  in 
the  causation  of  gall-stones,  this  catarrh  in  the  case  of  the 
gall-bladder  and  large  ducts  being  for  the  most  part  due  to 
infection  from  the  bowel,  and  in  the  case  of  the  smaller 
ducts  to  the  elimination  by  them  of  poisonous  substances 
from  the  blood.  The  second  great  factor  is  sluggishness  of 
the  bile-flow,  which  favours  the  formation  of  gall-stones 
not  only  directly,  but  also  indirectly,  by  inducing  catarrh.* 

This  second  factor  we  can  do  a  great  deal  to  remove. 
There  are  several  mechanical  interferences  with  the  active 
flow  of  bile.  Such  are  :  a  lax  state  of  the  abdominal  walls, 
which  allows  '  the  liver  to  fall  down,  so  that  the  fundus  of 
the  gall-bladder  is  considerably  below  the  level  of  the  junc- 
tion of  the  cystic  duct  with  the  hepatic  duct '  (Hunter) ;  a 

*  Brit.  Med.  Jour.,  1897,  vol.  ii.,  pp.  1235-1240.  Hunter  insists 
that  '  stagnation  alone  is  not  sufficient  to  cause  the  condition.'  That 
it  is  not  a  necessary  factor  is  shown  by  the  fact  that  gall-stones  va&y 
occur  in  those  leading  active  lives.  I  have  recently  had  under  observa- 
tion a  man  of  fine  physique  and  a  champion  runner  who  was  suffering 
from  complete  biliary  obstruction  owing  to  the  impaction  of  a  gall- 
stone in  the  common  duct. 


RESPIRATORY    EXERCISES   IN    OTHER    DISEASES     195 

sedentary  life,  in  which  the  liver  is  no  longer  shaken 
and  compressed  as  it  is  by  active  exercise  ;  and  interference 
with  the  proper  abdominal  breathing,  during  which  the 
liver  is  rhythmically  compressed  between  the  diaphragm 
and  anterior  abdominal  wall.  It  is  probably  in  this  way 
that  pregnancy  and  tight-lacing  favour  the  production  of 
gall-stones.  One  half  of  the  women  whose  livers  show 
evidence  post-mortem  of  tight-lacing  are  found  to  have 
them. 

From  these  considerations  it  is  manifest  that  anything 
which  favours  the  tiow  of  bile  tends  to  check  their  forma- 
tion, and  there  is  no  more  efficient  way  of  doing  this  than 
by  exercises  of  the  diaphragm  and  abdominal  muscles.  We 
should  also  seek  to  prevent  catarrh  of  the  bile-ducts  by 
keeping  the  alimentary  tract  in  a  healthy  state.  Finally, 
we  should  advise  the  drinking  of  large  quantities  of  water  ; 
for,  as  Lauder  Brunton  observes,  sufferers  from  gall-stones 
are  frequently  very  small  drinkers. 

Obesity. — It  is  a  well-recognised  fact  that  obesity  is  pre- 
disposed to  by  defective  oxygenation  of  the  tissues.  It  is 
for  this  reason  that  the  chlorotic  have  a  tendency  to  plump- 
ness. It  is  not  therefore  surprising  that  respiratory  exer- 
cises, by  increasing  blood  oxygenation,  should  tend  to  pro- 
mote fat  absorption.  It  should  be  remembered  in  this 
connection  that  great  obesity  favours  the  further  deposit  of 
fat  by  interfering  with  the  respiratory  movements,  and  thus 
with  the  proper  aeration  of  the  blood. 

Prolonged  treatment  by  means  of  the  compressed-air 
chamber  reduces  obesity. 

Anaemia. — Breathing  exercises  will  be  found  of  great 
service  in  the  treatment  of  anemia,  but  especially  of 
chlorosis.  It  is  evident  that  whatever  increases  the 
amount  of  oxygen  in  the  blood  when  this  fluid  is  defective 
in  it,  must  be  of  benefit. 

1:3—2 


]96  EESPIRATORY   EXERCISES 

Epistaxis. — For  this  a  writer  in  the  Medical  Annual  (1896, 
p.  290)  recommends  '  very  rapid  breathing  with  open  mouth, 
the  vowel  A  being  enunciated  with  each  expiration.' 

Stammering. — It  is  now  known  that  many  cases  of  stam- 
mering are  due  to  faulty  breathing,  and  in  consequence 
they  yield  to  breathing  exercises  systematically  carried 
out.     The  diaphragm  is  often  the  muscle  chiefly  at  fault. 

Hiccough. — An  old-fashioned  remedy  for  hiccough  is  to 
hold  the  breath  for  a  time.  The  best  plan  is  to  take  a 
series  of  rapid  diaphragmatic  breaths,  holding  the  breath 
at  intervals  for  as  long  as  possible,  with  the  object  of 
breaking  the  convulsive  habit  of  the  diaphragm. 

Sleeplessness. — Deep  breaths  are  very  helpful  in  inducing 
sleep. 


INDEX 


Addomex,  retraction  of,  5H 
Abdominiil  breathing,  pure,  67 
Abdominal  nuiscles,  action  of,  15 
effects  of,  on  the  circulation, 
13 
in  maintaining  the  vis- 
cera   in    their  proper 
position,  12 
exercises  for  developing  the, 

160 
means  of  testing  the  tone  of 
the,  16 
Abdominal  viscera,  effects  of  the 

respiratory  movements  on,  79 
Abdommal  walls,  in  the  child,  17 
in  man  and  woman  compared, 
18 
Active  breathing  exercises,  152 
Allchin,  19;} 
Antemia,   breathing  exercises  in, 

195 
Andral,  22 
Arnold,  33 

Asthma,   breathing   exercises   in, 
170 

Barnard.  Harold,  14,  24,  96 
Blake,  Edward,  96,  98,  153 
Bloodvessels,   compressibility   of, 

81 
Bradford,  143,  144 
Breath  force,  43 

in  disease,  45 
Breathing,  modes  of,  57,  61,  64 

in  singers,  64 

exercises,  148 


Breathlessness,    influence    of,    on 
mean  size  of  chest,  27 
on    respiratorv    movements, 
26 
Broadbent,  Sir  William,  97, 110  ii, 

120 
Bronchitis,     respiratory    exercise 

in,  168 
Brunton,  Lauder,  13,  195 
Budd,  176  H,  179 

Cathcart,  67,  69,  71-73,  74  n 
Chapman,  P.  M.,  83  ?^ 
Clarke,  W.  Bruce,  10,  12 
(•lavicular  breathing,  57,  64 
Cheval,  72,  73 
Cohnheim,  4,  143  n,  177  n 
ColUer,  Mayo,  65 
Compressed  air,  effect  of  innners- 

ing  body  in,  102 
Costal  breathing,  influence  of  sex 
upon,  55 

impediments  to,  129 

m  the  anthropoids,  55 

varieties  of,  57 

how  to  learn,  150 
Coughing,  effect  of,  on  intra-pul- 

monary  tension,  112 
Crying,  the  effects  of,  125 
Cycling,  observations  on,  163 

Dean,  143,  144  )i 

De  Jager,  81,  94  n 
I   Density  of  outer  air,  influence  of, 
1       on  the  circulation,  101 


198 


INDEX 


Diaphragm,      attachments      and 
functions  of,  50 
strength  of,  47 
Diaphragmatic  breathing,  how  to 
learn,  148 
impediments  to,  135 
Digestive      disorders,     breathing 

exercises  m,  192 
Donders,  43  n 
Douglas-PoweU,  Sir  E.,  4,  5,  21, 

22,  54  n,  177  «,  181 
Dyspnoea,  94,  142 

influence  of,  in  augmenting 
the  mean  size  of  the  chest, 
27 

Effort,  its  influence  on  the  cu'cu- 

lation,  113 
Elasticity  of  the  lungs,  1 

means  for  maintainmg,  7 
Elasticity  of  the  thoracic  cage,  19 

ends  served  by  the,  20 
Elder,  George,  on  the  cranial  cu'- 

culation,  98 
Emphysema,  breathing  exercises 

in,  183 
Emphj'sematous  chest,  28 

why  it  is  expanded,  175 
Expiratory  force,  43 
Expiratory        and        inspiratory 

muscles,   relative   strength    of, 

46 

Fetzer,  35 

Fixation  of  the  chest,  31,  33 
in  emphysema,  176 
influence  of,  on  the  circula- 
tion, 113 
Foster,  Michael,  81,  83,  88 
Fox,  Wilson,  29,  142,  175,  178  n, 

181 
Freund,  175 

Gall-stones,    breathing    exercises 

in,  194 
Guthrie,  Leonard,  24 

Hales,  43  it 

Heart,   susceptibility   of,    to    ex- 
ternal pressure,  82  j 
breatliing  exercises  in  disease   j 
of  the,  185 


HiU,  Leonard,  13,  14,  24.  82,  96, 

164 
Hoist,  Otto  L.,  159,  169,  170 
Hoper- Dixon,  153 
Hunter,  William,  194 
Hutchinson,  John,  19,  33,  43  n, 

54  n,  76,  77,  129  n 
Hyperoxygenation   of   the  blood, 

effects  of,  140 

Impediments  to  the  respiratory 
movements,  129 

Inspiratory  force,  43 

Insphatory  and  expiratory 
muscles,  relative  strength  of, 
46 

Intra-abdominal  tension,  9 

effects  of,  on  circulation,  13, 
90 

Intra-pulmonary  tension,  modifi- 
cations in,  112 

Jackson,  Hughlings,  122 
Jacobj',  170 

Joal,  61  n,  64?/,  66-68,  70  « 
Jemier,  Sir  William,  177  7i 
Johnstone,  Sir  George,  144 

Klein,  107 

Lagrange,  26,  93 
Laughter,  the  effects  of,  125 
Lees,  D.  B.,  143 
Ley den, 2  n,  5 
Lower  costal  breathing,  57 
Lungs,  movements  of,  witliin  the 
chest,  39 
respiratory       exercises       in 
diseases  of  the,  166 
Lymph,  influence  of  the  respira- 
tory movements  on  tlie  circula- 
tion of  the,  106 
Lymphatics  of  lung  and  pleura. 
106 

McCann,  34 

McKendric,  83  ti 

Mackenzie,  Sir  3Iortl.  60,  65,  72 

Mandl,  68 

Marcet,  W.,  140.  171 

Marey,  90 


INDEX 


199 


Mean  size  of  chest,  factors  deter- 
mining^ the,  25 
Metcalfe,  171 

Mobility  of  thoracic  cage,  ;52 
means  of  testing  the,  85 
exercises  for  increasing  the, 
172 
Morison,  Alexander,  1415 
IMountainous    regions,    the    effect 

of,  on  chest-capacitv,  27 
Miiller,  C.  W.,  76 
Miiller's  experiment,  6 
Muscle  exercise,  intluence  of,  on 
breathing,  111 

Nervous  mechanism  of  the  re- 
spiratory movements,  52 

Nervous  system,  respiratory  exer- 
cises in  diseases  of  the,  189 

Obesity,     influence      of      muscle 
activity  on,  11 
influence  of,  on  the  respira- 
tory movements,  130,  136 
influence  of,  on  the  circula- 
tion, 137 
breathing  exercises  in,  195 
Oertel,  38,  95,  101,  124,  130,  187, 
188 

Pancostal  breathing.  57,  65 

Passive  breathing  exercises,  157 

Perls,  4 

Phthinoid  chest,  27 

Phthisis,  respiratory  exercises  in 
the  treatment  of,  169 

Pleura,  the  functions  of  the,  37 
lower  limits  of  the,  38 

Pulmonary  disease,  breathing 
exercises  in,  168 

Pulse-rate,  influence  of  the  re- 
spiratory movements  on  the,  97 

Pulse-tension,  influence  of  the 
respiratory  movements  on,  94 

Quain,  52  n 

Quantity  of  air  that  can  be  in- 
spired by  the  different  methods 
of  breathing,  61 

Quincke,  2  n,  12 

Earefied  air,  effects  of,  102 


Residual  air,  quantity  of,  78 
Respiratory  force,  48 
Respiratory  movements,  impedi- 
ments to  the,  129 
physiological  modifications  in 

the,  109 
secondar^^  effects  of  the,  79 
influence  of,  on  the   circula- 
tion of  blood,  81 
influence  of,  on  the  circula- 
tion of  lymph,  106 
Retraction  of  the  abdomen,  58 
Roberts,  Frederick,  33 
Rosbach,  118 

Running,  effect  of,  on  the  respira- 
tory movements,  93 

Salter,  Hyde,  111  7i 
Sanderson,  Burdon,  54  n 
Sandow,  alterations  in  the  chest 

capacity  of,  36 
Savory,  Sir  William,  113 
Sex,  influence  on  the  breathing,  55 
Shouting,  the  effects  of,  121 
Sibson,  22,  38,  79  n,  80 
Singers,  breathing  in,  64 
Singing,  the  effects  of,  122 
Sleep,  influence  of,  on  the  respira- 
tory movements,  110 
on  the  circulation,  110 
Sneezing,    effects     of    an    intra- 

pulmonary  tension,  112 
Stays,  Nature's,  16 

effect    of    removing,   on  the 
circulation,  13 
Strength   of   inspiratory  and  ex- 
piratory muscles  compared,  46 
Suction,  pulmonax-y,  1 

its  influence  on  chest  capacity, 

25 
in  emphysema,  175 
in  phthisis,  26 
m  well-developed  lungs,  26 
influence  of,  on  the  circula- 
tion, 88 

Talking,  the  effects  of,  118 
Thoracic  cage,  mobility  of,  32,  35, 

172 
Thorax,  factors  determining  the 
mean  size  of  the,  25 
mode   in   which   the,   is   en- 
larged, 54 


200 


INDEX 


Tightlaciiig,  13,  96,  131,  133 
Transverse    abdominal    muscles, 

action  of  the,  13,  15 
Treves,  12 

Valsalva's  experiment,  7 
Vascular  tension,  influence  of  the 

respiratory      movements      on, 

94 
Vierorclt,  78 
Vital  capacity,  75 


Volition,   influence   of   breathing 

on,  141 
Vomiting,   influence    of,    on    the 

circulation,  112,  113 

Waldenburg,  43  ;/,  76,   101,   104, 

182  n 
Weber,  95 
Wintrich,  76 

Yawning,  effects  of,  127 


THE    END. 


JIaUliire,  TindalL  and  Oik,  20  and  21,  Kiwj  jl'illiahi  Slrat,  Straiui. 


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